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DSH390174CR THOMAS JEFFERSON UNIVERSITY HOSPITAL (Active)
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Main Details
Name
THOMAS JEFFERSON UNIVERSITY HOSPITAL
Subdivision Name
HB Clinic-Alg 211 - Asthma and Allergy
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH390174CR
Medicare Provider Number
390174
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
1/12/2024
Participating Start Date
4/1/2024
Participating Approval Date
3/6/2024
Last Recertification Date
9/5/2024
Contacts
Authorizing Official
Jefferson Health
Walter Wyatt, VP-Finance
(215) 254-3254
Primary Contact
Jefferson Health
Dustin Ottemiller, VP, Finance
(215) 503-5219
Addresses
Street Address
1101 Chestnut Street
17th Floor
Philadelphia, PA 19107
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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