Provider Demographics
NPI:1275720559
Name:MARTHA JEFFERSON MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:MARTHA JEFFERSON MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-654-5229
Mailing Address - Street 1:PO BOX 746550
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6550
Mailing Address - Country:US
Mailing Address - Phone:434-654-7340
Mailing Address - Fax:434-654-7752
Practice Address - Street 1:590 PETER JEFFERSON PKWY STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-4628
Practice Address - Country:US
Practice Address - Phone:434-654-7340
Practice Address - Fax:434-654-7752
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARTHA JEFFERSON HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-01
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207Q00000X, 207RP1001X, 207XS0106X, 208000000X, 208200000X, 208600000X, 208M00000X, 208000000X, 208200000X, 208600000X, 208M00000X, 207Q00000X, 208200000X, 207Q00000X
207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC10354Medicare PIN
VA6447890001Medicare NSC
VADH0041Medicare PIN