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DSH050174T ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital (Active)
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Main Details
Name
ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital
Subdivision Name
SANTA ROSA MEMORIAL HOSPITAL - Computed Tomography (CT) Scan
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH050174T
Medicare Provider Number
050174
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
1/17/2022
Participating Start Date
4/1/2022
Participating Approval Date
2/11/2022
Last Recertification Date
8/13/2024
Contacts
Authorizing Official
Providence St Joseph Health
Erika Wright, CFO
(707) 525-5300
Primary Contact
Providence
Jesse Peterson, 340B Program Director, South Division
(651) 324-2207
Addresses
Street Address
121 SOTOYOME ST
SANTA ROSA, CA 95405-4823
Billing Address
Santa Rosa Memorial Hospital
1165 Montgomery Drive
Santa Rosa, CA 95405
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating from effective date: (07/01/2019) until terminated (10/1/2020), reinstatement effective date: (04/01/2022)
02/11/2022
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