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DSH450194A ETMC JACKSONVILLE (Terminated)
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Main Details
Name
ETMC JACKSONVILLE
Subdivision Name
ETMC First Physicians Clinic Frankston
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH450194A
Medicare Provider Number
450194
Outpatient Facility Provider Number
458888
Additional Details
Current Program Status
Terminated
Registration Date
5/23/2012
Participating Start Date
7/1/2017
Participating Approval Date
6/13/2012
Last Recertification Date
11/6/2017
Termination Date
Termination Reason
4/1/2018
For-Profit conversion
Contacts
Authorizing Official
ETMC Jacksonville
Ruth A Cook, Administrator
(903) 541-5100
Primary Contact
ETMC Jacksonville
KENNETH KOO, DIRECTOR OF PHARMACY
(903) 541-5439
Addresses
Street Address
580 N. Frankston Highway
Frankston, TX 75763
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participated as DSH starting 7/1/2012, terminated 4/1/2013 when converted to DSH, reinstated as DSH 7/1/2017.
06/09/2017
Convert to SCH 4/1/13.”
04/10/2013
3/29/2013: Converted from DSH to SCH per entity request and OPA concurrence.
04/01/2013
convert to SCH 4/1/13
03/28/2013
April 2025
April 2025
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