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DSH390174B THOMAS JEFFERSON UNIVERSITY HOSPITAL (Active)
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Main Details
Name
THOMAS JEFFERSON UNIVERSITY HOSPITAL
Subdivision Name
Jefferson Hospital Ambulatory Practice
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH390174B
Medicare Provider Number
390174
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
10/10/2012
Participating Start Date
1/1/2013
Participating Approval Date
11/27/2012
Last Recertification Date
9/6/2024
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
33 South 9th Street
Suite 220
Philadelphia, PA 19107
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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