=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437420213
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARTHA JEFFERSON HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2012
-----------------------------------------------------
Last Update Date | 04/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 MARTHA JEFFERSON DR
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22911-4668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-654-3348
-----------------------------------------------------
Fax | 434-654-3353
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 MARTHA JEFFERSON DR BOX G288
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22911-4668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-654-3348
-----------------------------------------------------
Fax | 434-654-3353
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | J. MICHAEL BURRIS
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 434-654-7305
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 0201004441
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------