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DSH390174V THOMAS JEFFERSON UNIVERSITY HOSPITAL (Active)
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Main Details
Name
THOMAS JEFFERSON UNIVERSITY HOSPITAL
Subdivision Name
MHD Radiology - MRI
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH390174V
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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