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DSH140067A SAINT FRANCIS MEDICAL CENTER (Terminated)
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Main Details
Name
SAINT FRANCIS MEDICAL CENTER
Subdivision Name
Glen Avenue Diagnostic Center
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH140067A
Medicare Provider Number
140067
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/12/2012
Participating Start Date
1/1/2013
Participating Approval Date
11/27/2012
Last Recertification Date
8/30/2021
Termination Date
Termination Reason
10/1/2022
Site closure
Contacts
Authorizing Official
OSF Healthcare
Diane L. McGrew, President
(309) 655-2850
Primary Contact
OSF Healthcare
Jerry Storm, Senior Vice President of Pharmacy Services
(309) 655-3489
Addresses
Street Address
4911 Executive Drive
Level S
Peoria, IL 61614
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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