Basic Information
| Provider Information | |||||||||
| NPI: | 1760552434 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3624 MARKET ST | ||||||||
| Address2: | SUITE 560W | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191042614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156622286 | ||||||||
| FaxNumber: | 2156150500 | ||||||||
| Practice Location | |||||||||
| Address1: | 51 N 39TH ST | ||||||||
| Address2: | 7 FLOOR-MUTCH BUILDING | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191042640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156628777 | ||||||||
| FaxNumber: | 2152433290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 08/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSTON | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2156627583 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0361490000 | 01 | PA | KEYSTONE | OTHER | 30008890 | 01 | PA | MERCY | OTHER | 33655 | 01 | PA | HEALTHPARTNERS | OTHER |