Basic Information
| Provider Information | |||||||||
| NPI: | 1932449717 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEFFERSON UNIVERSITY PHYSICIANS | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JEFFERSON PALLIATIVE CARE PROGRAM | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 CHESTNUT ST FL 14 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191064495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159559655 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 925 CHESTNUT ST STE 420 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159558874 | ||||||||
| FaxNumber: | 2159552340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2013 | ||||||||
| LastUpdateDate: | 02/15/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MURPHY | ||||||||
| AuthorizedOfficialFirstName: | DIANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2159550804 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207QH0002X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1007729870101 | 05 | PA | MEDICAID |