Provider Demographics
NPI:1891722377
Name:JEFFERSON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:JEFFERSON MEMORIAL HOSPITAL
Other - Org Name:JEFFERSON MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:QUINONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-260-1443
Mailing Address - Street 1:PO BOX 1170
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-1170
Mailing Address - Country:US
Mailing Address - Phone:304-598-6795
Mailing Address - Fax:304-598-6381
Practice Address - Street 1:300 S. PRESTON STREET
Practice Address - Street 2:
Practice Address - City:RANSON
Practice Address - State:WV
Practice Address - Zip Code:25438-1631
Practice Address - Country:US
Practice Address - Phone:304-728-1600
Practice Address - Fax:304-725-9492
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST VIRGINIA UNIVERSITY HOSPITALS EAST INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-28
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV103282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004211Medicaid
VA005100682Medicaid
WV000304490OtherBLUE CROSS BLUE SHIELD
MD005805000Medicaid
WV3810004211Medicaid