Provider Demographics
NPI:1073693248
Name:JEFFERSON MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:JEFFERSON MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:M
Authorized Official - Last Name:EITELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-264-1244
Mailing Address - Street 1:300 S. PRESTON STREET
Mailing Address - Street 2:
Mailing Address - City:RANSON
Mailing Address - State:WV
Mailing Address - Zip Code:25438-1631
Mailing Address - Country:US
Mailing Address - Phone:304-728-1600
Mailing Address - Fax:304-725-9492
Practice Address - Street 1:300 S. PRESTON STREET
Practice Address - Street 2:
Practice Address - City:RANSON
Practice Address - State:WV
Practice Address - Zip Code:25438-1631
Practice Address - Country:US
Practice Address - Phone:304-728-1600
Practice Address - Fax:304-725-9492
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST VIRGINIA UNIVERSITY HOSPITALS EAST INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-16
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV103314000000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004211Medicaid
WV3810004211Medicaid
WV515157Medicare Oscar/Certification