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DSH450018CJ UNIVERSITY OF TEXAS MEDICAL BRANCH (Terminated)
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Main Details
Name
UNIVERSITY OF TEXAS MEDICAL BRANCH
Subdivision Name
UTMB LCC ADVANCED IMAGING CENTER
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH450018CJ
Medicare Provider Number
450018
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/15/2013
Participating Start Date
10/1/2013
Participating Approval Date
9/13/2013
Last Recertification Date
9/6/2019
Termination Date
Termination Reason
7/1/2020
Hospital Outpatient facility no longer eligible
Contacts
Authorizing Official
UTMB
Carolee A. King, Senior Vice President & General Counsel
(409) 772-1904
Primary Contact
UTMB
Sharon Chapman, Director of Operations
(409) 747-3509
Addresses
Street Address
2240 GULF FREEWAY SOUTH
SUITE 1.204
LEAGUE CITY, TX 77573
Billing Address
UTMB SPECIALTY CARE CENTER AT VICTORY LAKES
2240 GULF FREEWAY SOUTH
SUITE 2.203
LEAGUE CITY, TX 77573
Comments
Medicaid Billing
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Contract Pharmacies
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