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DSH250019U MEMORIAL HOSPITAL AT GULFPORT (Terminated)
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Main Details
Name
MEMORIAL HOSPITAL AT GULFPORT
Subdivision Name
Memorial Living Waters Community Medical Center
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH250019U
Medicare Provider Number
250019
Outpatient Facility Provider Number
700865
Additional Details
Current Program Status
Terminated
Registration Date
4/24/2012
Participating Start Date
7/1/2012
Participating Approval Date
6/25/2012
Last Recertification Date
9/4/2015
Termination Date
Termination Reason
1/1/2016
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
13472 Vidalia Rd
Pass Christian, MS 39571
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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