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PED453300-24 COOK CHILDREN'S MEDICAL CENTER (Terminated)
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Main Details
Name
COOK CHILDREN'S MEDICAL CENTER
Subdivision Name
Dodson Specialty Clinic ~ Hemophilia
Type
Children's Hospital
Rural
No
340B ID
PED453300-24
Medicare Provider Number
453300
Outpatient Facility Provider Number
453300
Additional Details
Current Program Status
Terminated
Registration Date
11/22/2013
Participating Start Date
1/1/2014
Participating Approval Date
12/12/2013
Last Recertification Date
8/17/2020
Termination Date
Termination Reason
10/1/2021
Hospital Outpatient facility no longer eligible
Contacts
Authorizing Official
Cook Children's Medical Center
Nancy Cychol, EVP, Hospital Services
(682) 885-4340
Primary Contact
Cook Children's Medical Center
Ashlee Hubbard, Strategic Business Manager, Finance
(682) 303-0423
Addresses
Street Address
1500 Cooper St
Fort Worth, TX 76104
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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