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RRC140160-00 FREEPORT MEMORIAL HOSPITAL (Terminated)
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Main Details
Name
FREEPORT MEMORIAL HOSPITAL
Subdivision Name
Type
Rural Referral Center
Rural
No
340B ID
RRC140160-00
Medicare Provider Number
140160
Additional Details
Current Program Status
Terminated
Registration Date
10/17/2016
Participating Start Date
1/1/2017
Participating Approval Date
11/1/2016
Last Recertification Date
11/16/2017
Termination Date
Termination Reason
7/1/2018
DSH percentage below statutory minimum
Contacts
Authorizing Official
FHN
Michael C. Clark, CFO
(815) 599-6361
Primary Contact
FHN Memorial
Michael Weaver, Director, Pharmacy Services
(815) 599-6113
Addresses
Street Address
1045 WEST STEPHENSON STREET
FREEPORT, IL 61032-4864
Billing Address
FHN MEMORIAL HOSPITAL
1045 WEST STEPHENSON STREET
FREEPORT, IL 61032-4864
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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