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DSH160064Q MercyOne North Iowa Medical Center (Terminated)
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Main Details
Name
MercyOne North Iowa Medical Center
Subdivision Name
MercyOne Clear Lake Pediatric & Adolescent Care
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH160064Q
Medicare Provider Number
160064
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/11/2019
Participating Start Date
10/1/2019
Participating Approval Date
7/26/2019
Last Recertification Date
8/19/2024
Termination Date
Termination Reason
1/1/2025
DSH percentage below statutory minimum
Contacts
Authorizing Official
MercyOne North Iowa Medical Center
Mark Trammel, HM VP Finance
(641) 428-7984
Primary Contact
MercyOne North Iowa Medical Center
Erin Brownmiller, 340B Program Manager
(641) 428-7024
Addresses
Street Address
401 S Fifteenth Street
Clear Lake, IA 50428-2303
Billing Address
MercyOne North Iowa Medical Center
1000 4th Street SW
Mason City, IA 50401
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating from effective date: (01/01/2017) until terminated effective date: (10/1/2018), reinstatement effective date: (10/01/2019)
07/25/2019
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