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RRC160057-24 Southeast Iowa Regional Medical Center (Terminated)
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Main Details
Name
Southeast Iowa Regional Medical Center
Subdivision Name
FM-PODIATRY - Podiatry
Type
Rural Referral Center
Rural
Yes
340B ID
RRC160057-24
Medicare Provider Number
160057
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/14/2021
Participating Start Date
10/1/2021
Participating Approval Date
8/25/2021
Last Recertification Date
Termination Date
Termination Reason
4/1/2022
Change of covered entity type
Contacts
Authorizing Official
Great River Health System
Jeremy Alexander, CFO
(319) 768-3280
Primary Contact
Great River Medical Center
Matthew J. Shivers, Director of Pharmacy
(319) 768-3971
Addresses
Street Address
5409 Avenue O
Fort Madison, IA 52627
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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