Basic Information
| Provider Information | |||||||||
| NPI: | 1376717538 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEFFERSON UNIVERSITY PHYSICIANS | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILY MEDICINE - SENIOR CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 MARKET ST FL 30 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191072934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159551175 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 33 S 9TH ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556664 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2008 | ||||||||
| LastUpdateDate: | 12/13/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RISTAS | ||||||||
| AuthorizedOfficialFirstName: | HRISTOS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF PROVIDER OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2159559298 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30025703 | 01 | PA | KEYSTONE MERCY | OTHER | 0060238007 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | 2977562 | 01 | PA | AETNA | OTHER |