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DSH370089F NORTHEASTERN HEALTH SYSTEM (Terminated)
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Main Details
Name
NORTHEASTERN HEALTH SYSTEM
Subdivision Name
TCH Infusion Clinic
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH370089F
Medicare Provider Number
370089
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/14/2013
Participating Start Date
1/1/2014
Participating Approval Date
12/2/2013
Last Recertification Date
11/7/2017
Termination Date
Termination Reason
4/1/2018
DSH percentage below statutory minimum
Contacts
Authorizing Official
Northeastern Health System
JAMES BERRY, EXEC VICE PRESIDENT
(918) 453-2263
Primary Contact
Northeastern Health System
William Ray Potts, Director of Pharmacy
(918) 453-2356
Addresses
Street Address
228 N Bliss Avenue
Tahlequah, OK 74464
Billing Address
Tahlequah City Hospital
PO Box 1008
Tahlequah, OK 74465
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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