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DSH050696R Keck Hospital of USC (Active)
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Main Details
Name
Keck Hospital of USC
Subdivision Name
PET Imaging Center
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH050696R
Medicare Provider Number
050696
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
4/12/2013
Participating Start Date
7/1/2013
Participating Approval Date
6/11/2013
Last Recertification Date
8/22/2024
Contacts
Authorizing Official
Keck Medicine of USC
Rod Hanners, Chief Operating Officer
(323) 442-8677
Primary Contact
Keck Medicine of USC
Krist Azizian, Chief Pharmacy Officer
(323) 865-3588
Addresses
Street Address
1510 San Pablo Street
Suite 350
Los Angeles, CA 90033
Billing Address
Keck Hospital of USC
1500 San Pablo
Los Angeles, CA 90033
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
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June 2025
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