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DSH010024R JACKSON HOSPITAL AND CLINIC INC (Terminated)
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Main Details
Name
JACKSON HOSPITAL AND CLINIC INC
Subdivision Name
Dr. Seirafi - General Surgery
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH010024R
Medicare Provider Number
010024
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
8/30/2022
Participating Start Date
9/7/2022
Participating Approval Date
9/7/2022
Last Recertification Date
8/21/2023
Termination Date
Termination Reason
10/1/2024
Site closure
Contacts
Authorizing Official
Jackson Hospital
Joe Riley, CEO
(334) 293-8809
Primary Contact
Jackson Hospital and Clinics
Thomas Hudson Cobb, Director of Pharmacy
(334) 293-8806
Addresses
Street Address
7201 Copperfield Drive
Montgomery, AL 36117
Billing Address
Jackson Hospital and Clinic
1725 Pine Street
Montgomery, AL 36106
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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