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DSH050696V Keck Hospital of USC (Active)
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Main Details
Name
Keck Hospital of USC
Subdivision Name
ENT Clinic
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH050696V
Medicare Provider Number
050696
Outpatient Facility Provider Number
050696
Additional Details
Current Program Status
Active
Registration Date
7/11/2014
Participating Start Date
10/1/2014
Participating Approval Date
9/4/2014
Last Recertification Date
8/22/2024
Contacts
Authorizing Official
Keck Medicine of USC
Rod Hanners, Chief Operating Officer
(323) 442-8677
Primary Contact
Keck Medicine of USC
Krist Azizian, Chief Pharmacy Officer
(323) 865-3588
Addresses
Street Address
1450 San Pablo
Suite 5100
Los Angeles, CA 90033-5313
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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