Basic Information
Provider Information | |||||||||
NPI: | 1689848830 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JEFFERSON UNIVERSITY PHYSICIANS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OB/GYN- GENERAL | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/18/2008 | ||||||||
LastUpdateDate: | 10/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RISTAS | ||||||||
AuthorizedOfficialFirstName: | HRISTOS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP | ||||||||
AuthorizedOfficialTelephone: | 2159559298 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 0052967000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | 1002144 | 01 | PA | KEYSTONE MERCY | OTHER | 45169 | 01 | PA | KEYSTONE MERCY | OTHER | 170919 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 477737 | 01 | PA | AETNA | OTHER | 7609400 | 05 | NJ |   | MEDICAID |