Basic Information
| Provider Information | |||||||||
| NPI: | 1346248663 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARTHA JEFFERSON HOSPITAL | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2556 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229022556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4346547000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 MARTHA JEFFERSON DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229114668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4346547000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2005 | ||||||||
| LastUpdateDate: | 01/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | BROERMANN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7574557020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 01/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | H1872 | VA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 004900774 | 05 | VA | MEDICAID | 000012 | 01 | VA | BLUE CROSS PROVIDER NUMBE | OTHER |