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DSH500014N PROV REGL MED CENTER EVERETT (Terminated)
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Main Details
Name
PROV REGL MED CENTER EVERETT
Subdivision Name
Pacific Campus / Maternal Fetal Medicine Clinic
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH500014N
Medicare Provider Number
500014
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/7/2016
Participating Start Date
7/1/2016
Participating Approval Date
5/11/2016
Last Recertification Date
8/11/2016
Termination Date
Termination Reason
7/1/2017
Site closure
Contacts
Authorizing Official
Providence Health & Services Washington
Scott Combs, CFO
(425) 261-4044
Primary Contact
Providence Health & Services Washington
Eric Werttemberger, Director of Pharmacy
(425) 261-3530
Addresses
Street Address
916 PACIFIC AVE
EVERETT, WA 98201-4147
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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