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DSH030122K BANNER GATEWAY MEDICAL CENTER (Terminated)
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Main Details
Name
BANNER GATEWAY MEDICAL CENTER
Subdivision Name
MD ANDERSON CLINIC - WELLNESS PROGRAM - WELLNESS PROGRAMS-CLINIC
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH030122K
Medicare Provider Number
030122
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/1/2021
Participating Start Date
1/1/2022
Participating Approval Date
10/12/2021
Last Recertification Date
8/23/2023
Termination Date
Termination Reason
1/1/2024
Site closure
Contacts
Authorizing Official
Banner University Medical Center Phoenix
Cody W Ziemer, Chief Financial Officer
(602) 839-8507
Primary Contact
Banner Gateway Medical Center
Tanya Nacy, Pharmacy Director
(480) 543-2190
Addresses
Street Address
2946 E BANNER GATEWAY DRIVE
1ST FLOOR
GILBERT, AZ 85234
Billing Address
BANNER HEALTH ACCOUNTS PAYABLE
PO BOX 2977
PHOENIX, AZ 85062
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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