Basic Information
Provider Information | |||||||||
NPI: | 1114995156 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE PENNSYLVANIA HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA HEALTH SYS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1500 MARKET ST | ||||||||
Address2: | UPPER MEZZANINE 600 | ||||||||
City: | PHILA | ||||||||
State: | PA | ||||||||
PostalCode: | 191022100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2157620630 | ||||||||
FaxNumber: | 2157620754 | ||||||||
Practice Location | |||||||||
Address1: | 800 SPRUCE ST | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191076130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2157620630 | ||||||||
FaxNumber: | 2157620754 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2006 | ||||||||
LastUpdateDate: | 07/09/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCORMICK | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AVP FINANCE | ||||||||
AuthorizedOfficialTelephone: | 2157620888 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X |   |   | Y |   | Hospital Units | Rehabilitation Unit |   |
ID Information
ID | Type | State | Issuer | Description | 1000049150009 | 05 | PA |   | MEDICAID |