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DSH370089A NORTHEASTERN HEALTH SYSTEM (Terminated)
Main Details
Name
NORTHEASTERN HEALTH SYSTEM
Subdivision Name
TAHLEQUAH MEDICAL GROUP BY-PASS 1
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH370089A
Medicare Provider Number
370089
Outpatient Facility Provider Number
Contacts
Authorizing Official
Northeastern Health System
JAMES BERRY, EXEC VICE PRESIDENT
(918) 453-2263
Primary Contact
Northeastern Health System
William Ray Potts, Director of Pharmacy
(918) 453-2356
Additional Details
Current Program Status
Terminated
Registration Date
12/8/2010
Participating Start Date
1/1/2011
Participating Approval Date
12/15/2010
Last Recertification Date
11/7/2017
Termination Date
4/1/2018
Termination Reason
DSH percentage below statutory minimum
Addresses
Street Address
1201 E. ROSS BYPASS
TAHLEQUAH, OK 74464
Billing Address
TAHLEQUAH CITY HOSPITAL
P.O BOX 1008
TAHLEQUAH, OK 74465-1005
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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