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DSH320084 ROOSEVELT GENERAL HOSPITAL (Active)
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Main Details
Name
ROOSEVELT GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH320084
Medicare Provider Number
320084
Additional Details
Current Program Status
Active
Registration Date
10/10/2016
Participating Start Date
1/1/2017
Participating Approval Date
10/26/2016
Last Recertification Date
8/15/2024
Contacts
Authorizing Official
Roosevelt General Hospital
Andrea King, CFO
(575) 356-3406
Primary Contact
Roosevelt General Hospital
LaDawna Brooks, Chief of Diagnostics and Therapeutics
(575) 359-1800 Ext: 3456
Addresses
Street Address
42121 US HIGHWAY 70
PORTALES, NM 88130
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Last Recertification date 09/22/2020
09/22/2020
April 2025
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