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DSH100017P HALIFAX HEALTH MEDICAL CENTER (Terminated)
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Main Details
Name
HALIFAX HEALTH MEDICAL CENTER
Subdivision Name
Halifax Behavioral Services
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH100017P
Medicare Provider Number
100017
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/2/2018
Participating Start Date
10/1/2018
Participating Approval Date
7/19/2018
Last Recertification Date
9/3/2021
Termination Date
Termination Reason
10/1/2022
Hospital Outpatient facility no longer eligible
Contacts
Authorizing Official
Halifax Hospital Medical Center
ERIC M. PEBURN, CFO
(386) 425-4568
Primary Contact
Halifax Health Medical Center
Crystal A Lue, Director, Reimbursement and Revenue
(386) 425-7382
Addresses
Street Address
841 Jimmy Ann Dr.
Daytona Beach, FL 32117
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participated starting 7/1/2015, terminated 5/2/2018. Reinstated 10/1/2018.
07/19/2018
Participated starting 7/1/2015, terminated 5/2/2018. Reinstated 10/1/2018.
07/19/2018
May 2025
May 2025
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