Provider Demographics
NPI:1902824071
Name:MARTHA JEFFERSON HOSPTIAL
Entity Type:Organization
Organization Name:MARTHA JEFFERSON HOSPTIAL
Other - Org Name:MARTHA JEFFERSON NUTRITIONAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-654-7305
Mailing Address - Street 1:PO BOX 75268
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-5268
Mailing Address - Country:US
Mailing Address - Phone:434-654-7794
Mailing Address - Fax:434-654-7752
Practice Address - Street 1:500 MARTHA JEFFERSON DRIVE
Practice Address - Street 2:COMMUNITY SERVICES
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-4668
Practice Address - Country:US
Practice Address - Phone:434-654-4407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARTHA JEFFERSON HOSPTIAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-17
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC00221Medicare PIN
VACB4590Medicare PIN