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DSH240019AV SMDC MEDICAL CENTER (Terminated)
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Main Details
Name
SMDC MEDICAL CENTER
Subdivision Name
Essentia Health Proctor Clinic / Non Invasive - Proc
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH240019AV
Medicare Provider Number
240019
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/14/2016
Participating Start Date
4/1/2016
Participating Approval Date
3/8/2016
Last Recertification Date
8/29/2019
Termination Date
Termination Reason
4/1/2020
Other
Contacts
Authorizing Official
Essentia Health
Bradley Beard, Chief Operating Officer
(218) 786-2652
Primary Contact
Essentia Health
Bryan Lundberg, 340b Program Manager
(218) 828-7143
Addresses
Street Address
211 South Boundary Avenue
Proctor, MN 55810
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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