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DSH390174AA THOMAS JEFFERSON UNIVERSITY HOSPITAL (Active)
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Main Details
Name
THOMAS JEFFERSON UNIVERSITY HOSPITAL
Subdivision Name
MHD Mammography
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH390174AA
Medicare Provider Number
390174
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
4/11/2014
Participating Start Date
7/1/2014
Participating Approval Date
6/5/2014
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
2301 South Broad Street
Philadelphia, PA 19148
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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