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DSH450037H GOOD SHEPHERD MEDICAL CENTER (Terminated)
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Main Details
Name
GOOD SHEPHERD MEDICAL CENTER
Subdivision Name
Infusion Clinic
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH450037H
Medicare Provider Number
450037
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/17/2017
Participating Start Date
7/1/2017
Participating Approval Date
4/25/2017
Last Recertification Date
8/28/2018
Termination Date
Termination Reason
7/1/2019
Other
Contacts
Authorizing Official
Christus Good Shepherd Medical Center
Jason Adams, COO
(903) 315-2440
Primary Contact
Christus Good Shepherd Medical Center
Jonathan Taylor Brown, Director
(903) 315-2019
Addresses
Street Address
700 E MARSHALL AVE
LONGVIEW, TX 75601-5580
Billing Address
Good Shepherd Medical Center - Longview
700 E. Marshall Ave
Longview, TX 75601
Comments
Medicaid Billing
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Parent/Child
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