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DSH520087CJ Gundersen Lutheran Medical Center, Inc. (Terminated)
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Main Details
Name
Gundersen Lutheran Medical Center, Inc.
Subdivision Name
GUNDERSEN LUTHERAN MEDICAL CENTER I / Renal OP - Viroqua
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH520087CJ
Medicare Provider Number
520087
Outpatient Facility Provider Number
523517
Additional Details
Current Program Status
Terminated
Registration Date
1/12/2018
Participating Start Date
4/1/2018
Participating Approval Date
2/21/2018
Last Recertification Date
9/5/2023
Termination Date
Termination Reason
10/1/2024
Site closure
Contacts
Authorizing Official
Gundersen Health system
Michelle Micka, VP Finance
(608) 775-3131 Ext: 53131
Primary Contact
Gundersen Health System
Loren Carrell, Director
(608) 775-6369
Addresses
Street Address
407S MAIN ST 300
VIROQUA, WI 54665-4001
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Started participation 1/1/2015; Terminated on 7/1/2017; Reinstated on 4/1/2018.
02/20/2018
April 2025
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