Basic Information
| Provider Information | |||||||||
| NPI: | 1902063605 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENN PRESBYTERIAN MEDICAL CENTER SPU | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 MARKET ST | ||||||||
| Address2: | UPPER MEZZANINE 600 | ||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191022100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157964640 | ||||||||
| FaxNumber: | 2157620754 | ||||||||
| Practice Location | |||||||||
| Address1: | 51 N 39TH ST | ||||||||
| Address2: | |||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191042640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157964640 | ||||||||
| FaxNumber: | 2157620754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2008 | ||||||||
| LastUpdateDate: | 01/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | MCCORMICK | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSOCIATE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2157620888 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1007297070017 | 05 | PA | MEDICAID |