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DSH100022S JACKSON MEMORIAL (Terminated)
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Main Details
Name
JACKSON MEMORIAL
Subdivision Name
PHT DR RAFAEL A PENALVER CLINIC
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH100022S
Medicare Provider Number
100022
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/15/2014
Participating Start Date
1/1/2015
Participating Approval Date
12/4/2014
Last Recertification Date
Termination Date
Termination Reason
7/1/2015
Site closure
Contacts
Authorizing Official
Jackson Health System
Carlos A. Migoya, CEO
(305) 585-6754
Primary Contact
Jackson Health System
Carlos A. Migoya, CEO
(305) 585-6754
Addresses
Street Address
971 NW 2ND AVENUE
MIAMI, FL 33128-1205
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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