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DSH330044R Faxton St. Luke's Healthcare (Terminated)
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Main Details
Name
Faxton St. Luke's Healthcare
Subdivision Name
Renal Dialysis - SLH
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH330044R
Medicare Provider Number
330044
Outpatient Facility Provider Number
333568
Additional Details
Current Program Status
Terminated
Registration Date
4/15/2014
Participating Start Date
7/1/2014
Participating Approval Date
4/25/2014
Last Recertification Date
9/1/2023
Termination Date
Termination Reason
10/1/2023
Change of covered entity type (non-hospital)
Contacts
Authorizing Official
MVHS Inc, DBA Wynn Hospital
Louis Aiello, Sr. VP Finance/ CFO
(315) 917-8213
Primary Contact
MVHS, Inc. DBA: Wynn Hospital
James Humphrey, AVP Finance/ Controller
(315) 801-4326
Addresses
Street Address
1650 Champlin Ave.
Utica, NY 13502
Billing Address
Faxton St. Luke's Healthcare
1676 Sunset Ave.
Utica, NY 13502
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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