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DSH140185X MEMORIAL HOSPITAL (Terminated)
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Main Details
Name
MEMORIAL HOSPITAL
Subdivision Name
MHB COL LAB - Lab
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH140185X
Medicare Provider Number
140185
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/12/2022
Participating Start Date
10/1/2022
Participating Approval Date
8/4/2022
Last Recertification Date
Termination Date
Termination Reason
7/1/2023
DSH percentage below statutory minimum
Contacts
Authorizing Official
Memorial Hospital
Michael McManus, President
(618) 257-5642
Primary Contact
Memorial Hospital
Ryan Birk, Director of Pharmacy
(618) 606-0210
Addresses
Street Address
200 Admiral Trost Road
1B
Columbia, IL 62236
Billing Address
BJC Healthcare
4249 Clayton Avenue
310
St. Louis, MO 63110
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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