Provider Demographics
NPI:1942397153
Name:MARTHA JEFFERSON HOSPITAL
Entity Type:Organization
Organization Name:MARTHA JEFFERSON HOSPITAL
Other - Org Name:MJ REPRODUCTIVE TECHNOLOGY LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/COO
Authorized Official - Prefix:
Authorized Official - First Name:ELLIOT
Authorized Official - Middle Name:H
Authorized Official - Last Name:KUIDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-982-7326
Mailing Address - Street 1:595 PETER JEFFERSON PKWY
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911
Mailing Address - Country:US
Mailing Address - Phone:434-982-8520
Mailing Address - Fax:434-982-8530
Practice Address - Street 1:595 PETER JEFFERSON PKWY
Practice Address - Street 2:3RD FLOOR
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911
Practice Address - Country:US
Practice Address - Phone:434-982-8520
Practice Address - Fax:434-982-8530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA186753OtherANTHEM SERVICES