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DSH160067Q MercyOne Waterloo Medical Center (ToBeTerminated)
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Main Details
Name
MercyOne Waterloo Medical Center
Subdivision Name
MercyOne Dysart Family Medicine
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH160067Q
Medicare Provider Number
160067
Outpatient Facility Provider Number
Additional Details
Current Program Status
ToBeTerminated
Registration Date
2/28/2011
Participating Start Date
4/1/2011
Participating Approval Date
3/2/2011
Last Recertification Date
9/5/2024
Termination Date
Termination Reason
7/1/2025
Site closure
Contacts
Authorizing Official
MercyOne NorthEast Iowa
Timothy Huber, Vice President of Finance
(319) 272-7607
Primary Contact
Covenant Medical Center
Jaclyn Annette Van Raden, 340B Contract Pharmacy Analyst
(319) 272-8636
Addresses
Street Address
501 CLARK ST
DYSART, IA 52224
Billing Address
MercyOne Medical Group Northeast Iowa
PO BOX 6200
WATERLOO, IA 50704
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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