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DSH240019B SMDC Medical Center (Terminated)
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Main Details
Name
SMDC Medical Center
Subdivision Name
Essentia Health First Street Clinic
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH240019B
Medicare Provider Number
240019
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/7/2013
Participating Start Date
4/1/2013
Participating Approval Date
3/7/2013
Last Recertification Date
9/8/2015
Termination Date
Termination Reason
10/1/2015
Other
Contacts
Authorizing Official
Essentia Health
Bradley Beard, Chief Operating Officer
(218) 786-2652
Primary Contact
Essentia Health
Bryan Lundberg, 340b Program Manager
(218) 828-7143
Addresses
Street Address
420 East First Street
Duluth, MN 55805
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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