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DSH350015AD SANFORD BISMARCK (Terminated)
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Main Details
Name
SANFORD BISMARCK
Subdivision Name
SANFORD BISMARCK / Downtown Internal Medicine Clinic
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH350015AD
Medicare Provider Number
350015
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/25/2019
Participating Start Date
4/1/2019
Participating Approval Date
1/29/2019
Last Recertification Date
8/19/2020
Termination Date
Termination Reason
10/1/2021
Site closure
Contacts
Authorizing Official
Sanford Bismarck
Kirk Cristy, Vice President Finance
(701) 323-6000 Ext: 6310
Primary Contact
Sanford Bismarck
John Savageau, Director - Pharmacy
(701) 323-6186
Addresses
Street Address
515 E Broadway Ave
BISMARCK, ND 58501-4437
Billing Address
Sanford Bismarck
300 N 7th St
Bismarck, ND 58501
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating from effective date (07/1/2016) until terminated effective date (01/01/2019), reinstatement effective date (04/01/2019
01/29/2019
Participating from effective date (05/11/2016) until terminated effective date (01/01/2019), reinstatement effective date (04/01/2019)
01/28/2019
April 2025
April 2025
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