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CAH521329-44 ST MARYS HOSPITAL OF SUPERIOR (Active)
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Main Details
Name
ST MARYS HOSPITAL OF SUPERIOR
Subdivision Name
Essentia Health Spooner Clinic - General Pediatrics
Type
Critical Access Hospital
Rural
No
340B ID
CAH521329-44
Medicare Provider Number
521329
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
1/26/2021
Participating Start Date
4/1/2021
Participating Approval Date
1/28/2021
Last Recertification Date
8/18/2024
Contacts
Authorizing Official
Essentia Health
Bradley Beard, Chief Operating Officer
(218) 786-2652
Primary Contact
Essentia Health
Nick Sharrow, Pharmacy Business Services Director
(218) 606-9246
Addresses
Street Address
1180 Chandler Drive
Spooner, WI 54801
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating from effective date: (4/1/2019), until terminated effective date: (04/01/2020), reinstatement effective date: (04/01/2021)
01/28/2021
May 2025
May 2025
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