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DSH240004AF HENNEPIN COUNTY MEDICAL CENTER (Terminated)
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Main Details
Name
HENNEPIN COUNTY MEDICAL CENTER
Subdivision Name
Addiction Medicine Clinic
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH240004AF
Medicare Provider Number
240004
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/9/2015
Participating Start Date
10/1/2015
Participating Approval Date
7/16/2015
Last Recertification Date
Termination Date
Termination Reason
1/1/2016
Site closure
Contacts
Authorizing Official
Hennepin County Medical Center - Hennepin Healthcare Inc
Emily Blomberg, Chief Operating Official
(612) 873-9913
Primary Contact
Hennepin County Medical Center
Michael Pitzl, Pharmacy Director
(612) 873-9917
Addresses
Street Address
701 PARK AVE
MINNEAPOLIS, MN 55415-1623
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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