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DSH440063B JOHNSON CITY MEDICAL CENTER (Terminated)
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Main Details
Name
JOHNSON CITY MEDICAL CENTER
Subdivision Name
Regional Cancer Center @ Johnson City Medical Center
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH440063B
Medicare Provider Number
440063
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/10/2013
Participating Start Date
1/1/2014
Participating Approval Date
12/13/2013
Last Recertification Date
8/7/2015
Termination Date
Termination Reason
10/1/2016
Site closure
Contacts
Authorizing Official
Mountain States Health Alliance
Shane Hilton, VP/CFO - Market Operations
(423) 302-3467
Primary Contact
MSHA
Trish Tanner, AVP Pharmacy Services
(423) 302-3532
Addresses
Street Address
2205 Pavilion Drive
Suite 101
Kingsport, TN 37660-4641
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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12/3/13 I'm not sure that AO/SBO is at high enough level, pls chk 12/4/13: Changed AO to Chief Financial officer.
12/04/2013
12/3/13 I'm not sure that AO/SBO is at high enough level, pls chk
12/03/2013
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