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CAH521329-63 ST MARYS HOSPITAL OF SUPERIOR (Terminated)
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Main Details
Name
ST MARYS HOSPITAL OF SUPERIOR
Subdivision Name
Essentia Health Hayward Clinic - Physical Therapy
Type
Critical Access Hospital
Rural
No
340B ID
CAH521329-63
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
8/27/2019
Termination Date
Termination Reason
4/1/2020
Other
Contacts
Authorizing Official
Essentia Health
Kim Pearson, Administrator
(715) 817-7017
Primary Contact
Essentia Health
Bryan Lundberg, 340b Program Manager
(218) 828-7143
Addresses
Street Address
11134 N State Road 77
Hayward, WI 54843
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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