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DSH240084BA ESSENTIA HEALTH VIRGINIA (Terminated)
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Main Details
Name
ESSENTIA HEALTH VIRGINIA
Subdivision Name
Essentia Health Virginia Clinic / Urology
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH240084BA
Medicare Provider Number
240084
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/12/2017
Participating Start Date
4/1/2017
Participating Approval Date
3/13/2017
Last Recertification Date
11/22/2017
Termination Date
Termination Reason
7/1/2018
Outpatient facility moved within the 4 walls of the parent hospital
Contacts
Authorizing Official
Essentia Health
Sam Stone, COO
(218) 742-8600 Ext: 2496
Primary Contact
Essentia Health
Bryan Lundberg, 340b Program Manager
(218) 576-0745
Addresses
Street Address
1101 9th Street North
Virginia, MN 55792
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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