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DSH230053SR HENRY FORD HOSPITAL (Terminated)
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Main Details
Name
HENRY FORD HOSPITAL
Subdivision Name
Henry Ford Medical Center West Bloomfield Athletic Medicine
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH230053SR
Medicare Provider Number
230053
Outpatient Facility Provider Number
230053
Additional Details
Current Program Status
Terminated
Registration Date
7/11/2014
Participating Start Date
10/1/2014
Participating Approval Date
9/15/2014
Last Recertification Date
8/27/2015
Termination Date
Termination Reason
10/1/2016
Site closure
Contacts
Authorizing Official
Henry Ford Hospital
Doug Clark, SVP - Corporate Finance
(313) 874-5446
Primary Contact
Henry Ford Hospital
Alexander Mansour, 340B Compliance Officer
(248) 723-0020
Addresses
Street Address
6777 West Maple Road
West Bloomfield, MI 48322
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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