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DSH050174K ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital (Terminated)
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Main Details
Name
ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital
Subdivision Name
SRMH - Physical Therapy Services (Rehabilitation Services)
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH050174K
Medicare Provider Number
050174
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/12/2015
Participating Start Date
4/1/2015
Participating Approval Date
3/6/2015
Last Recertification Date
8/16/2018
Termination Date
Termination Reason
7/1/2019
Business decision by the Covered Entity
Contacts
Authorizing Official
St. Joseph Health
Kevin Klockenga, CEO
(707) 522-1520
Primary Contact
St.Joseph Health
Virginia Elizabeth Schuchard, NorCal Region 340B Program Manager
(507) 271-8661
Addresses
Street Address
1170 Montgomery Drive
Santa Rosa, CA 95405
Billing Address
Santa Rosa Memorial Hospital
1165 Montgomery Drive
Santa Rosa, CA 95405
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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