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DSH250019DP MEMORIAL HOSPITAL AT GULFPORT (Terminated)
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Main Details
Name
MEMORIAL HOSPITAL AT GULFPORT
Subdivision Name
MEMORIAL HOSPITAL AT GULFPORT / Acadian- Gastroenterology
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH250019DP
Medicare Provider Number
250019
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/5/2024
Participating Start Date
7/1/2024
Participating Approval Date
4/10/2024
Last Recertification Date
Termination Date
Termination Reason
10/1/2024
Business decision by the Covered Entity
Contacts
Authorizing Official
Memorial Hospital at Gulfport
Kent Nicaud, President and Chief Executive Officer
(228) 867-4046
Primary Contact
Memorial Hospital at Gulfport
Brian Clark, Outpatient Pharmacy Director
(228) 867-4485
Addresses
Street Address
12261 HWY 49 NORTH
STE 11
GULFPORT, MS 39503-2975
Billing Address
Memorial Hospital at Gulfport
4500 13th Street
Gulfport, MS 39501
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participated starting- 7/1/2016 Terminated starting- 10/1/2019 Reinstated- 7/1/2024
04/10/2024
April 2025
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