Basic Information
Provider Information | |||||||||
NPI: | 1639343890 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JEFFERSON UNIVERSITY PHYSICIANS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UROLOGY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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 STE 703 | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191074408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2159551000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/18/2008 | ||||||||
LastUpdateDate: | 12/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RISTAS | ||||||||
AuthorizedOfficialFirstName: | HRISTOS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF NETWORK OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 2159559298 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 2370033000 | 01 | PA | AMERIHEALTH | OTHER | 7548109 | 05 | NJ |   | MEDICAID | 120728 | 01 | PA | AETNA | OTHER | 32944 | 01 | PA | KEYSTONE MERCY | OTHER | 0445135000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | 959635 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER |