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DSH030122C BANNER GATEWAY MEDICAL CENTER (Terminated)
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Main Details
Name
BANNER GATEWAY MEDICAL CENTER
Subdivision Name
Banner Gateway Occupational Health
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH030122C
Medicare Provider Number
030122
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/8/2016
Participating Start Date
4/1/2016
Participating Approval Date
2/12/2016
Last Recertification Date
9/7/2016
Termination Date
Termination Reason
7/1/2017
Site closure
Contacts
Authorizing Official
Banner University Medical Center Phoenix
Cody W Ziemer, Chief Financial Officer
(602) 839-8507
Primary Contact
Banner Gateway Medical Center
Tanya Nacy, Pharmacy Director
(480) 543-2190
Addresses
Street Address
1920 North Higley Road
Gilbert, AZ 85234
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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