Basic Information
| Provider Information | |||||||||
| NPI: | 1285622100 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEMPLE UNIVERSITY OF THE COMMONWEALTH SYSTEM OF HIGHER EDUCATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TEMPLE GENERAL INTERNAL MEDICINE ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 W HUNTING PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157071800 | ||||||||
| FaxNumber: | 2157073644 | ||||||||
| Practice Location | |||||||||
| Address1: | 3322 N. BROAD ST. | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191405103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157071800 | ||||||||
| FaxNumber: | 2157073644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 06/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | WOODARD | ||||||||
| AuthorizedOfficialFirstName: | TONYA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER,CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 2157073911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1007780130721 | 05 | PA | MEDICAID | 1007780130718 | 05 | PA | MEDICAID |