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DSH250019CK MEMORIAL HOSPITAL AT GULFPORT (Terminated)
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Main Details
Name
MEMORIAL HOSPITAL AT GULFPORT
Subdivision Name
Memorial Physician Clinic Waveland
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH250019CK
Medicare Provider Number
250019
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/9/2015
Participating Start Date
4/1/2015
Participating Approval Date
3/6/2015
Last Recertification Date
9/6/2016
Termination Date
Termination Reason
10/2/2017
Site closure
Contacts
Authorizing Official
Memorial Hospital at Gulfport
Kent Nicaud, President and Chief Executive Officer
(228) 867-4046
Primary Contact
Memorial Hospital at Gulfport
Brian Clark, Outpatient Pharmacy Director
(228) 867-4485
Addresses
Street Address
200 US 90
Waveland, MS 39576
Billing Address
Memorial Hospital at Gulfport
4500 13th Street
Gulfport, MS 39501
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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