Basic Information
| Provider Information | |||||||||
| NPI: | 1225452303 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARTHA JEFFERSON HOSPITAL | ||||||||
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| OtherOrganizationName: | MARTHA JEFFERSON OUTPATIENT SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 MARTHA JEFFERSON DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229114668 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 595 MARTHA JEFFERSON DR | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229114669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4346547000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2014 | ||||||||
| LastUpdateDate: | 08/20/2014 | ||||||||
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| AuthorizedOfficialLastName: | BROERMANN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7574557020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARTHA JEFFERSON HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.