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DSH050696N Keck Hospital of USC (Active)
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Main Details
Name
Keck Hospital of USC
Subdivision Name
Ambulatory Surgery Center
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH050696N
Medicare Provider Number
050696
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
3/23/2012
Participating Start Date
7/1/2012
Participating Approval Date
6/27/2012
Last Recertification Date
8/22/2024
Contacts
Authorizing Official
Keck Medicine of USC
Rod Hanners, Chief Operating Officer
(323) 442-8677
Primary Contact
Keck Medicine of USC
Krist Azizian, Chief Pharmacy Officer
(323) 865-3588
Addresses
Street Address
1537 Norfolk Street
1st FL
Los Angeles, CA 90033
Billing Address
Keck Hosital of USC
1500 San Pablo
Los Angeles, CA 90033
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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June 2025
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