Basic Information
| Provider Information | |||||||||
| NPI: | 1063541779 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF PENN-ANESTHESIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 SPRUCE ST | ||||||||
| Address2: | 4 DULLES | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153498310 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3400 SPRUCE ST | ||||||||
| Address2: | 4 DULLES | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153498310 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 07/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSTON | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2156627583 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207LC0200X | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 542967 | 01 | PA | AETNA | OTHER | 0056969000 | 01 | PA | KEYSTONE | OTHER | 401256 | 01 | PA | BLUE SHEILD | OTHER | 0006733040 | 05 | PA | MEDICAID |