Healthcare Provider Details

I. General information

NPI: 1275720559
Provider Name (Legal Business Name): MARTHA JEFFERSON MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 PETER JEFFERSON PKWY STE 300
CHARLOTTESVILLE VA
22911-4628
US

IV. Provider business mailing address

PO BOX 746550
ATLANTA GA
30374-6550
US

V. Phone/Fax

Practice location:
  • Phone: 434-654-7340
  • Fax: 434-654-7752
Mailing address:
  • Phone: 434-654-7340
  • Fax: 434-654-7752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number StateVA
# 6
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number StateVA
# 7
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateVA
# 8
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateVA

VIII. Authorized Official

Name: DR. BRUCE CLEMONS
Title or Position: VICE PRESIDENT, MEDICAL DIRECTOR
Credential: MD
Phone: 434-654-5229