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RRC140046-09 GOOD SAMARITAN REGIONAL HEALTH CTR. (Terminated)
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Main Details
Name
GOOD SAMARITAN REGIONAL HEALTH CTR.
Subdivision Name
Offsite Imaging / Diagnostics
Type
Rural Referral Center
Rural
Yes
340B ID
RRC140046-09
Medicare Provider Number
140046
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/7/2015
Participating Start Date
1/1/2016
Participating Approval Date
11/9/2015
Last Recertification Date
8/20/2019
Termination Date
Termination Reason
4/1/2020
Site closure
Contacts
Authorizing Official
Good Samaritan Hospital
Jeremy Shawn Bradford, President
(618) 899-1002
Primary Contact
SSM Health
Jeffrey Peine, Finance Director
(314) 989-3532
Addresses
Street Address
501 DuQuoin St
Benton, IL 62812
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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May 2025
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