Provider Demographics
NPI:1912228628
Name:MARTHA JEFFERSON HOSPITAL
Entity Type:Organization
Organization Name:MARTHA JEFFERSON HOSPITAL
Other - Org Name:THE SOMETHING SPECIAL SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-455-7020
Mailing Address - Street 1:590 PETER JEFFERSON PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-4628
Mailing Address - Country:US
Mailing Address - Phone:434-654-8574
Mailing Address - Fax:
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:434-654-7042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARTHA JEFFERSON HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-16
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4900774Medicaid
VA4900774Medicaid
VA6478400001Medicare NSC