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DSH140206P Humboldt Park Health (Terminated)
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Main Details
Name
Humboldt Park Health
Subdivision Name
NORWEGIAN AMERICAN HOSPITAL INC / Surgical Consultants
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH140206P
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
8/16/2021
Termination Date
Termination Reason
6/16/2022
Hospital Outpatient facility no longer eligible
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 502
CHICAGO, IL 60622-3644
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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