Basic Information
| Provider Information | |||||||||
| NPI: | 1912477324 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEFFERSON UNIVERSITY PHYSCIANS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JEFFERSON PRIMARY CARE AT THE NAVY YARD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 828937 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191828937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155031240 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3 CRESCENT DR FL 2 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191121016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155033210 | ||||||||
| FaxNumber: | 2155037136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2018 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRIGHT-BUTLER | ||||||||
| AuthorizedOfficialFirstName: | VALERIE | ||||||||
| AuthorizedOfficialMiddleName: | YVETTE | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSOC DIRECTOR OF ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 2159559457 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JEFFERSON UNIVERSITY PHYSCIANS | ||||||||
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| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.