Basic Information
| Provider Information | |||||||||
| NPI: | 1184898322 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEFFERSON UNIVERSITY PHYSICIANS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OB/GYN- MATERNAL & FETAL MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 828937 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191828937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155031240 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 33 S 9TH ST FL 1 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159555000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2008 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RISTAS | ||||||||
| AuthorizedOfficialFirstName: | HRISTOS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2159559298 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 599438 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 2649567 | 01 | PA | AETNA | OTHER | 1053524 | 01 | PA | KEYSTONE MERCY | OTHER | 099425 | 01 | PA | AETNA | OTHER | 0421844000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | 1016835 | 01 | PA | KEYSTONE MERCY | OTHER |