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DSH490017AC Maryview Hospital LLC (Terminated)
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Main Details
Name
Maryview Hospital LLC
Subdivision Name
Pain Management Center - Pain Management
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH490017AC
Medicare Provider Number
490017
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/11/2022
Participating Start Date
1/1/2023
Participating Approval Date
11/15/2022
Last Recertification Date
8/23/2024
Termination Date
Termination Reason
4/1/2025
Site closure
Contacts
Authorizing Official
Bon Secours Mercy Health
Jonathan Lee Haynes, Hampton Roads Market CFO
(540) 270-2809
Primary Contact
Bon Secours Mercy Health
Diana Willman, Pharmacy Director
(757) 398-2192
Addresses
Street Address
3640 High Street
Suite 3A
Portsmouth, VA 23707
Billing Address
Bon Secours Maryview Medical Center
3636 High Street
Portsmouth, VA 23707
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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June 2025
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