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DSH330047Z ST. MARYS HEALTHCARE (Terminated)
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Main Details
Name
ST. MARYS HEALTHCARE
Subdivision Name
Children's Mental Health Clinic
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH330047Z
Medicare Provider Number
330047
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/13/2017
Participating Start Date
10/1/2017
Participating Approval Date
7/25/2017
Last Recertification Date
8/14/2024
Termination Date
Termination Reason
4/1/2025
Other
Contacts
Authorizing Official
St. Mary's Healthcare
Keith Waters, Vice President of Finance/CFO
(518) 770-7583
Primary Contact
St. Mary's Healthcare
Tami Wessel, 340B Program Lead
(518) 256-1163
Addresses
Street Address
4988 State Highway 30
Amsterdam, NY 12010
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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April 2025
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