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DSH520177E FROEDTERT MEMORIAL LUTHERAN HOSPITAL (Terminated)
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Main Details
Name
FROEDTERT MEMORIAL LUTHERAN HOSPITAL
Subdivision Name
Sports Medicine Radiology
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH520177E
Medicare Provider Number
520177
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
9/2/2020
Termination Date
Termination Reason
10/1/2021
Business decision by the Covered Entity
Contacts
Authorizing Official
Froedtert Memorial Lutheran Hospital
James Klauck, Senior Vice President, Ancillary Services
(414) 777-1925
Primary Contact
Froedtert Memorial Lutheran Hospital
Jacob Olson, 340B Program Manager
(262) 532-5184
Addresses
Street Address
8700 Watertown Plank Road
Wauwatosa, WI 53226
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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