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RRC230019-08 ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL (Active)
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Main Details
Name
ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL
Subdivision Name
PROVIDENCE MEDICAL CTR-SOUTH LYON - Providence Medical Center South Lyon
Type
Rural Referral Center
Rural
Yes
340B ID
RRC230019-08
Medicare Provider Number
230019
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
4/14/2023
Participating Start Date
7/1/2023
Participating Approval Date
5/2/2023
Last Recertification Date
8/15/2024
Contacts
Authorizing Official
Henry Ford Hospital
Doug Clark, SVP - Corporate Finance
(313) 874-5446
Primary Contact
Henry Ford Hospital
Alexander Mansour, 340B Compliance Officer
(248) 723-0020
Addresses
Street Address
210 N LAFAYETTE ST
SOUTH LYON, MI 48178-2048
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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