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DSH390174BF THOMAS JEFFERSON UNIVERSITY HOSPITAL (Active)
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Main Details
Name
THOMAS JEFFERSON UNIVERSITY HOSPITAL
Subdivision Name
HB Clinic / Family Medicine
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH390174BF
Medicare Provider Number
390174
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
10/14/2016
Participating Start Date
1/1/2017
Participating Approval Date
11/4/2016
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 301
Philadelphia, PA 19107
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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