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DSH340003A NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY (Terminated)
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Main Details
Name
NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY
Subdivision Name
REVIVAL PAIN MANAGEMENT
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH340003A
Medicare Provider Number
340003
Outpatient Facility Provider Number
232278
Additional Details
Current Program Status
Terminated
Registration Date
4/14/2014
Participating Start Date
7/1/2014
Participating Approval Date
5/22/2014
Last Recertification Date
9/5/2018
Termination Date
Termination Reason
4/1/2019
DSH percentage below statutory minimum
Contacts
Authorizing Official
Northern Hospital
Robin Hodgin, VP Patient Care Services
(336) 719-7019
Primary Contact
Northern Hospital of Surry County
DARRELL ESTES, DIRECTOR OF PHARMACY
(336) 719-7120
Addresses
Street Address
110 DUTCHMAN'S COURT
ELKIN, NC 28621
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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