Provider Demographics
NPI:1437420213
Name:MARTHA JEFFERSON HOSPITAL
Entity Type:Organization
Organization Name:MARTHA JEFFERSON HOSPITAL
Other - Org Name:SENTARA MARTHA JEFFERSON OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP, CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:J. MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BURRIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:434-654-7305
Mailing Address - Street 1:500 MARTHA JEFFERSON DR
Mailing Address - Street 2:BOX G288
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-4668
Mailing Address - Country:US
Mailing Address - Phone:434-654-3348
Mailing Address - Fax:434-654-3353
Practice Address - Street 1:500 MARTHA JEFFERSON DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-4668
Practice Address - Country:US
Practice Address - Phone:434-654-3348
Practice Address - Fax:434-654-3353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010044413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1437420213Medicaid
2133540OtherPK