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DSH230165AA ST JOHN HOSPITAL & MEDICAL CENTER (Terminated)
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Main Details
Name
ST JOHN HOSPITAL & MEDICAL CENTER
Subdivision Name
St John Internal Medicine Residency Clinic/St John Hospital and Medical Center
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH230165AA
Medicare Provider Number
230165
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/10/2014
Participating Start Date
4/1/2014
Participating Approval Date
2/27/2014
Last Recertification Date
12/5/2017
Termination Date
Termination Reason
10/1/2018
Site closure
Contacts
Authorizing Official
St John Providence
Douglas Winner, CFO, Acute Care Operations
(586) 753-0662
Primary Contact
St John Hospital and Medical Center
Gary Blake, Director Pharmacy
(313) 343-3763
Addresses
Street Address
7633 East Jefferson Ave Suite 170
Detroit, MI 48214
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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