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DSH230053ET HENRY FORD HOSPITAL (Terminated)
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Main Details
Name
HENRY FORD HOSPITAL
Subdivision Name
Henry Ford Medical Center Southfield Pediatrics
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH230053ET
Medicare Provider Number
230053
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
5/10/2012
Participating Start Date
7/1/2012
Participating Approval Date
5/30/2012
Last Recertification Date
8/31/2022
Termination Date
Termination Reason
10/1/2023
Site closure
Contacts
Authorizing Official
Henry Ford Hospital
Doug Clark, SVP - Corporate Finance
(313) 874-5446
Primary Contact
Henry Ford Hospital
Alexander Mansour, 340B Compliance Officer
(248) 723-0020
Addresses
Street Address
22777 W. Eleven Mile Road
Southfield, MI 48034
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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