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DSH250019GR MEMORIAL HOSPITAL AT GULFPORT (Terminated)
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Main Details
Name
MEMORIAL HOSPITAL AT GULFPORT
Subdivision Name
MEMORIAL HOSPITAL AT GULFPORT - Gaddy Vision
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH250019GR
Medicare Provider Number
250019
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/13/2021
Participating Start Date
10/1/2021
Participating Approval Date
8/17/2021
Last Recertification Date
8/26/2022
Termination Date
Termination Reason
1/1/2023
Business decision by the Covered Entity
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
10051 LORRAINE RD
GULFPORT, MS 39503-6001
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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