Basic Information
| Provider Information | |||||||||
| NPI: | 1295909422 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEFFERSON UNIVERSITY PHYSICIANS | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NEUROLOGY- GENERAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 828937 SUITE 630 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191828937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155031240 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 833 CHESTNUT ST | ||||||||
| Address2: | SUITE 630 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159550800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2008 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | RISTAS | ||||||||
| AuthorizedOfficialFirstName: | HRISTOS | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 2159559298 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 48506 | 01 | PA | KEYSTONE MERCY | OTHER | 0444973000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | 7696507 | 05 | NJ | MEDICAID | 959656 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 955345 | 01 | PA | AETNA | OTHER |