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DSH140012AA KATHERINE SHAW BETHEA (Terminated)
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Main Details
Name
KATHERINE SHAW BETHEA
Subdivision Name
Mt Morris Clinic
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH140012AA
Medicare Provider Number
140012
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/11/2017
Participating Start Date
10/1/2017
Participating Approval Date
7/21/2017
Last Recertification Date
8/21/2018
Termination Date
Termination Reason
7/1/2019
DSH percentage below statutory minimum
Contacts
Authorizing Official
Katherine Shaw Bethea Hospital
Julie D. Mann, VP/CAO
(815) 285-5538
Primary Contact
Katherine Shaw Bethea Hospital
Julie D. Mann, VP/CAO
(815) 285-5538
Addresses
Street Address
405 Charles Street
Mt. Morris, IL 61054
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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