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DSH330044AW Faxton St. Luke's Healthcare (Terminated)
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Main Details
Name
Faxton St. Luke's Healthcare
Subdivision Name
SAUQUOIT MEDICAL OFFICE
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH330044AW
Medicare Provider Number
330044
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/5/2017
Participating Start Date
7/1/2017
Participating Approval Date
4/26/2017
Last Recertification Date
8/26/2019
Termination Date
Termination Reason
10/1/2020
Site closure
Contacts
Authorizing Official
MVHS Inc, DBA Wynn Hospital
Louis Aiello, Sr. VP Finance/ CFO
(315) 917-8213
Primary Contact
MVHS, Inc. DBA: Wynn Hospital
James Humphrey, AVP Finance/ Controller
(315) 801-4326
Addresses
Street Address
2888 ONEIDA ST
SAUQUOIT, NY 13456-3110
Billing Address
Faxton St. Luke's Healthcare
1676 Sunset Ave.
Utica, NY 13502
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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