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RRC100307-07 ST. VINCENTS MEDICAL CENTER SOUTHSID (Terminated)
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Main Details
Name
ST. VINCENTS MEDICAL CENTER SOUTHSID
Subdivision Name
PULMONARY CLAY - PULMONOLOGY
Type
Rural Referral Center
Rural
Yes
340B ID
RRC100307-07
Medicare Provider Number
100307
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/4/2024
Participating Start Date
4/1/2024
Participating Approval Date
2/20/2024
Last Recertification Date
8/19/2024
Termination Date
Termination Reason
4/1/2025
Other
Contacts
Authorizing Official
Sacred Heart Health System, Inc.
Susan Cornejo, Chief Operating Officer
(850) 416-6206
Primary Contact
Sacred Heart Health System, Inc.
Troy Russo, 340B Coordinator
(850) 416-2859
Addresses
Street Address
1658 ST VINCENTS WAY
STE 100
MIDDLEBURG, FL 32068-8459
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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