Basic Information
Provider Information | |||||||||
NPI: | 1477660173 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY OF PENN - MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3400 SPRUCE ST | ||||||||
Address2: | 3 DULLES | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191044206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2153498222 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3400 SPRUCE ST | ||||||||
Address2: | 3 DULLES BUILDING | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191044206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2153498222 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2006 | ||||||||
LastUpdateDate: | 11/19/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JACKSON | ||||||||
AuthorizedOfficialFirstName: | CHANTE | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | ENROLLMENT LEAD | ||||||||
AuthorizedOfficialTelephone: | 2156626187 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/19/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 0002Y20116 | 01 | PA | HEALTHNET | OTHER | 0322705000 | 01 | PA | KEYSTONE | OTHER | 1010509 | 01 | PA | MERCY | OTHER | 0006610360 | 05 | PA |   | MEDICAID | 10706 | 01 | PA | HEALTHPARTNERS | OTHER | 273194 | 01 | PA | MAMSI | OTHER | 5465605 | 01 | NJ | NJ-MEDICAID | OTHER | CA0235 | 01 | PA | RR MEDICARE | OTHER | G0003165 | 01 | PA | AMERICHOICE | OTHER | 063598 | 01 | PA | BLUE SHIELD | OTHER | 496672 | 01 | PA | AETNA | OTHER |