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DSH100025Z SACRED HEART HEALTH SYSTEM (Terminated)
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Main Details
Name
SACRED HEART HEALTH SYSTEM
Subdivision Name
SACRED HEART MEDICAL GROUP - ASSOCIATE HEALTHCARE CLINIC
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH100025Z
Medicare Provider Number
100025
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
12/6/2010
Participating Start Date
1/1/2011
Participating Approval Date
12/22/2010
Last Recertification Date
8/19/2015
Termination Date
Termination Reason
10/1/2015
Site closure
Contacts
Authorizing Official
Sacred Heart Health System, Inc.
Susan Cornejo, Chief Operating Officer
(850) 416-6206
Primary Contact
Steve Poole, Director Medical Practices
(850) 416-7039
Addresses
Street Address
1549 AIRPORT BLVD.
SUITE 200E
PENSACOLA, FL 32504
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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