Basic Information
| Provider Information | |||||||||
| NPI: | 1023373511 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3624 MARKET ST | ||||||||
| Address2: | SUITE 560W | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191042614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156622286 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3400 SPRUCE ST | ||||||||
| Address2: | GROUND FLOOR DONNER | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156626698 | ||||||||
| FaxNumber: | 2156623953 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2012 | ||||||||
| LastUpdateDate: | 07/10/2012 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSTON | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 2156627583 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | PA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207PE0004X | PA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
No ID Information.