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DSH450034AG CHRISTUS HOSPITAL (Terminated)
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Main Details
Name
CHRISTUS HOSPITAL
Subdivision Name
CHRISTUS SOUTHEAST TEXAS Orthopedic Specialty Center Mid County
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH450034AG
Medicare Provider Number
450034
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/6/2021
Participating Start Date
5/25/2021
Participating Approval Date
4/23/2021
Last Recertification Date
8/16/2021
Termination Date
Termination Reason
10/1/2022
Business decision by the Covered Entity
Contacts
Authorizing Official
CHRISTUS Hospital
Paul Trevino, CEO, CHRISTUS Health Southeast Texas
(409) 899-7102
Primary Contact
CHRISTUS Health
Santosh Kalathra, Director of Pharmacy
(409) 236-7042
Addresses
Street Address
2501 Jimmy Johnson Blvd., Ste 400
Port Arthur, TX 77642
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating from effective date: (04/01/2015) until terminated effective date: (01/01/2018), reinstatement effective date: (05/25/2021)
05/21/2021
April 2025
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