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DSH140206M Humboldt Park Health (Terminated)
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Main Details
Name
Humboldt Park Health
Subdivision Name
Physician Specialty and Eye Center
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH140206M
Medicare Provider Number
140206
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/13/2016
Participating Start Date
4/1/2016
Participating Approval Date
2/19/2016
Last Recertification Date
9/16/2022
Termination Date
Termination Reason
10/1/2023
Other
Contacts
Authorizing Official
Humboldt Park Health
Thomas Garvey, Chief Financial Officer
(773) 292-8200 Ext: 8208
Primary Contact
Humboldt Park Health
Ravina Gandhakwala, Director of Pharmacy
(773) 292-8200 Ext: 7380
Addresses
Street Address
1044N MOZART ST 500
CHICAGO, IL 60622-3644
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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