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DSH010158A RUSSELLVILLE HOSPITAL (Terminated)
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Main Details
Name
RUSSELLVILLE HOSPITAL
Subdivision Name
RUSSELLVILLE HOSPITAL INC - Family Practice
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH010158A
Medicare Provider Number
010158
Outpatient Facility Provider Number
013478
Additional Details
Current Program Status
Terminated
Registration Date
4/8/2021
Participating Start Date
7/1/2021
Participating Approval Date
4/8/2021
Last Recertification Date
8/29/2022
Termination Date
Termination Reason
10/1/2023
Failure to recertify
Contacts
Authorizing Official
Russellville Hospital
Stephen Maurice Proctor, Chief Executive Officer
(256) 332-8679
Primary Contact
Russellville Hospital
Tracy Darryl Vinson, Supervising Pharmacist
(256) 332-8628
Addresses
Street Address
15225 HIGHWAY 43
STE I
RUSSELLVILLE, AL 35653-1969
Billing Address
Russellville Hospital
15155 Hwy 43
Russellville, AL 35653
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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