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DSH260142B JOHN FITZGIBBON MEMORIAL HOSPITAL (Active)
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Main Details
Name
JOHN FITZGIBBON MEMORIAL HOSPITAL
Subdivision Name
Grand River Medical Clinic
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH260142B
Medicare Provider Number
260142
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
10/21/2019
Participating Start Date
1/1/2020
Participating Approval Date
10/23/2019
Last Recertification Date
9/3/2024
Contacts
Authorizing Official
John Fitzgibbon Memorial Hospital
Angy P. Littrell, President & CEO
(660) 831-3251
Primary Contact
John Fitzgibbon Memorial Hospital, Inc.
Cheryl Lynn Cunningham, Compliance Officer
(660) 831-3767
Addresses
Street Address
815 E. Broadway
Brunswick, MO 65236
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participated starting 1/1/2019, terminated 10/1/2019. Reinstated 1/1/2020.
10/22/2019
Initial start 10/1/2015, Termination 10/1/2017, Reinstate 1/1/2019
10/18/2018
8/21/15 participating 1/1/14 thru 9/30/14, not participating 10/1/14 thru 9/30/15 due to DSH % below statutory minimum, reinstated based on on-line registration submitted in July 2015
08/21/2015
10/21/14 Provider # temporarily removed to facility re-registration as a different entity type
10/22/2014
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