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DSH050696P Keck Hospital of USC (Terminated)
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Main Details
Name
Keck Hospital of USC
Subdivision Name
Surgery Clinic
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH050696P
Medicare Provider Number
050696
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
3/26/2012
Participating Start Date
7/1/2012
Participating Approval Date
6/27/2012
Last Recertification Date
9/4/2015
Termination Date
Termination Reason
1/1/2016
Site closure
Contacts
Authorizing Official
Keck Medicine of USC
Rod Hanners, Chief Operating Officer
(323) 442-8677
Primary Contact
Keck Medicine of USC
EVELYN WING, 340B MANAGER
(323) 865-3611
Addresses
Street Address
1510 San Pablo Street, 5th Floor
Suite 514
Los Angeles, CA 90033
Billing Address
Keck Hospital of USC
1500 San Pablo
Los Angeles, CA 90033
Comments
Medicaid Billing
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