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DSH240084BS ESSENTIA HEALTH VIRGINIA LLC (Terminated)
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Main Details
Name
ESSENTIA HEALTH VIRGINIA LLC
Subdivision Name
Essentia Health International Falls Clinic - Endocrinology
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH240084BS
Medicare Provider Number
240084
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/11/2019
Participating Start Date
4/1/2019
Participating Approval Date
1/23/2019
Last Recertification Date
8/29/2019
Termination Date
Termination Reason
1/1/2020
DSH percentage below statutory minimum
Contacts
Authorizing Official
Essentia Health
Sam Stone, COO
(218) 742-8600 Ext: 2496
Primary Contact
Essentia Health
Bryan Lundberg, 340b Program Manager
(218) 828-7143
Addresses
Street Address
2501 Keenan Drive
International Falls, MN 56649
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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