Basic Information
| Provider Information | |||||||||
| NPI: | 1245207521 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRESBYTERIAN MEDICAL CENTER OF THE UNIVERSITY OF PENNSYLVANIA HEALTH S | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UPHS PRESBYTERIAN MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 MARKET ST | ||||||||
| Address2: | UPPER MEZZENINE 600 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191022100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157964640 | ||||||||
| FaxNumber: | 6097707792 | ||||||||
| Practice Location | |||||||||
| Address1: | 51 N 39TH ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191042640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157964640 | ||||||||
| FaxNumber: | 6097707792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2006 | ||||||||
| LastUpdateDate: | 12/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | MCCORMICK | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | AVP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2157620888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 282N00000X | PA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1007297070011 | 05 | PA | MEDICAID |