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DSH490017X BON SECOURS MARYVIEW MEDICAL CENTER (Terminated)
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Main Details
Name
BON SECOURS MARYVIEW MEDICAL CENTER
Subdivision Name
MMC Center for Pain Management
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH490017X
Medicare Provider Number
490017
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/14/2015
Participating Start Date
1/1/2016
Participating Approval Date
11/9/2015
Last Recertification Date
9/4/2019
Termination Date
Termination Reason
4/1/2020
Site closure
Contacts
Authorizing Official
MaryView Medical Center
John Carr Simmerman, CFO
(757) 398-2133
Primary Contact
Bon Secours
Coley W Deal, 340B Program Manager
(804) 221-4837
Addresses
Street Address
3315 High Street
Portsmouth, VA 23707
Billing Address
Maryview Medical Center
3636 High Street
Portsmouth, VA 23707
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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