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RRC330011-39 OUR LADY OF LOURDES MEMORIAL HOSP (Terminated)
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Main Details
Name
OUR LADY OF LOURDES MEMORIAL HOSP
Subdivision Name
Vestal / Occupational Health
Type
Rural Referral Center
Rural
Yes
340B ID
RRC330011-39
Medicare Provider Number
330011
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/12/2017
Participating Start Date
4/1/2017
Participating Approval Date
2/16/2017
Last Recertification Date
9/4/2019
Termination Date
Termination Reason
7/1/2020
Hospital Outpatient facility no longer eligible
Contacts
Authorizing Official
Our Lady of Lourdes Memorial Hospital, Inc.
Kathryn Connerton, CEO
(607) 798-5328
Primary Contact
Ascension Health - OLOL, SMH, SAH
Michael Vincent Simeck, 340B Program Manager
(607) 584-5462
Addresses
Street Address
3101 Shippers Road
Vestal, NY 13850
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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June 2025
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