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DSH230053MX HENRY FORD HOSPITAL (Active)
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Main Details
Name
HENRY FORD HOSPITAL
Subdivision Name
Henry Ford Medical Center Cottage Radiology
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH230053MX
Medicare Provider Number
230053
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
7/16/2018
Participating Start Date
10/1/2018
Participating Approval Date
7/18/2018
Last Recertification Date
8/25/2024
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
159 Kercheval Avenue
Grosse Pointe Farms, MI 48236
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Initial Start date 10/1/2012, termination 10/1/2016, reinstate 10/1/2018
07/18/2018
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