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DSH250019Q MEMORIAL HOSPITAL AT GULFPORT (Terminated)
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Main Details
Name
MEMORIAL HOSPITAL AT GULFPORT
Subdivision Name
Memorial Gulf Coast Pediatrics at Bridgewater Center
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH250019Q
Medicare Provider Number
250019
Outpatient Facility Provider Number
700865
Additional Details
Current Program Status
Terminated
Registration Date
4/23/2012
Participating Start Date
7/1/2012
Participating Approval Date
6/25/2012
Last Recertification Date
12/4/2017
Termination Date
Termination Reason
4/1/2018
Site closure
Contacts
Authorizing Official
Memorial Hospital at Gulfport
Kent Nicaud, President and Chief Executive Officer
(228) 867-4046
Primary Contact
Memorial Hospital at Gulfport
Brian Clark, Outpatient Pharmacy Director
(228) 867-4485
Addresses
Street Address
8950 Lorraine Road
Suite A
Gulfport, MS 39503
Billing Address
Memorial Hospital at Gulfport
4500 13th Street
Gulfport, MS 39501
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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