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DSH130049H KOOTENAI MEDICAL CENTER (Terminated)
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Main Details
Name
KOOTENAI MEDICAL CENTER
Subdivision Name
KOOTENAI FAMILY & INTERNAL MEDICINE
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH130049H
Medicare Provider Number
130049
Outpatient Facility Provider Number
130049
Additional Details
Current Program Status
Terminated
Registration Date
7/14/2014
Participating Start Date
10/1/2014
Participating Approval Date
9/10/2014
Last Recertification Date
Termination Date
Termination Reason
7/1/2015
Loss of qualifying grant/support
Contacts
Authorizing Official
Kootenai Health
Kim Webb, CFO
(208) 625-4001
Primary Contact
Jeremy S. Evans, Vice President
(208) 625-4002
Addresses
Street Address
925 E POLSTON AVENUE
POST FALLS, ID 83854-9049
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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