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DSH240019AQ SMDC MEDICAL CENTER (Terminated)
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Main Details
Name
SMDC MEDICAL CENTER
Subdivision Name
Essentia Health Second Street Clinic / Skin Renewal Clinic
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH240019AQ
Medicare Provider Number
240019
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/29/2014
Participating Start Date
1/1/2015
Participating Approval Date
11/21/2014
Last Recertification Date
9/8/2015
Termination Date
Termination Reason
10/1/2015
Other
Contacts
Authorizing Official
Essentia Health
Bradley Beard, Chief Operating Officer
(218) 786-2652
Primary Contact
Essentia Health
Bryan Lundberg, 340b Program Manager
(218) 828-7143
Addresses
Street Address
502 East 2nd Street
Duluth, MN 55805
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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