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DSH250019FE MEMORIAL HOSPITAL AT GULFPORT (Active)
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Main Details
Name
MEMORIAL HOSPITAL AT GULFPORT
Subdivision Name
The Medical Oncology Group (TMOG)
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH250019FE
Medicare Provider Number
250019
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
1/14/2019
Participating Start Date
4/1/2019
Participating Approval Date
1/24/2019
Last Recertification Date
8/29/2024
Contacts
Authorizing Official
Memorial Hospital at Gulfport
Kent Nicaud, President and Chief Executive Officer
(228) 867-4046
Primary Contact
Memorial Hospital at Gulfport
Brian Clark, Outpatient Pharmacy Director
(228) 867-4485
Addresses
Street Address
1340 BROAD AVE
STE 270
GULFPORT, MS 39501-2404
Billing Address
Memorial Hospital at Gulfport
4500 13th Street
Gulfport, MS 39501
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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