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CAH521329-48 ST MARYS HOSPITAL OF SUPERIOR (Terminated)
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Main Details
Name
ST MARYS HOSPITAL OF SUPERIOR
Subdivision Name
Essentia Health Spooner Clinic - Physical Medicine & Rehab
Type
Critical Access Hospital
Rural
No
340B ID
CAH521329-48
Medicare Provider Number
521329
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/9/2019
Participating Start Date
4/1/2019
Participating Approval Date
1/24/2019
Last Recertification Date
8/29/2023
Termination Date
Termination Reason
7/1/2024
Business decision by the Covered Entity
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 DR
SPOONER, WI 54801
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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