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DSH050254W MARSHALL HOSPITAL (Terminated)
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Main Details
Name
MARSHALL HOSPITAL
Subdivision Name
MARSHALL GASTROENTEROLOGY PLACERVILLE - GI PLACERVILLE
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH050254W
Medicare Provider Number
050254
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/11/2018
Participating Start Date
1/1/2019
Participating Approval Date
10/17/2018
Last Recertification Date
8/25/2022
Termination Date
Termination Reason
7/1/2023
Other
Contacts
Authorizing Official
Marshall Medical Center
Siri Nelson, CEO
(707) 349-8127
Primary Contact
Marshall Medical Center
Stephanie A Godon, Director of Pharmacy
(530) 626-2703
Addresses
Street Address
1095 MARSHALL WAY SUITE 101
PLACERVILLE, CA 95667
Billing Address
Marshall Medical Center - Accounts Payable
P.O. Box # 872
Placerville, CA 95667
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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