Basic Information
| Provider Information | |||||||||
| NPI: | 1649300617 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEMPLE UNIVERSITY OF THE COMMONWEALTH SYSTEM OF HIGHER EDUCATION | ||||||||
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| OtherOrganizationName: | TEMPLE PEDIATRIC HEMATOLOGY ONCOLOGY ASSOC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3425 N CARLISLE ST | ||||||||
| Address2: | 2ND FL HUDSON BUILDING | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191405108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157073911 | ||||||||
| FaxNumber: | 2157073677 | ||||||||
| Practice Location | |||||||||
| Address1: | 3509 N BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191404105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157076613 | ||||||||
| FaxNumber: | 2157076629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | TRACEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, GOVERNMENT AND PAYER RELA | ||||||||
| AuthorizedOfficialTelephone: | 2157074739 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0207X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1007780130698 | 05 | PA | MEDICAID |