Basic Information
| Provider Information | |||||||||
| NPI: | 1982717641 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF PENN-MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 CIVIC CENTER BLVD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191045127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156622454 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3400 CIVIC CENTER BLVD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191045127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156622454 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 11/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | CHANTE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | ENROLLMENT LEAD | ||||||||
| AuthorizedOfficialTelephone: | 2156626187 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RR0500X | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 0276505000 | 01 | PA | KEYSTONE | OTHER | CA0235 | 01 | PA | RR MEDICARE | OTHER | 5443300 | 01 | NJ | NJ-MEDICAID | OTHER | 496695 | 01 | PA | AETNA | OTHER | 140756 | 01 | PA | BLUE SHIELD | OTHER | 0006610360 | 05 | PA | MEDICAID | 1010975 | 01 | PA | MERCY | OTHER | 0002Y20116 | 01 | PA | HEALTHNET | OTHER | 273257 | 01 | PA | MAMSI | OTHER | 020255499 | 01 | PA | EEIOC | OTHER | 31848 | 01 | PA | HEALTHPARTNERS | OTHER | G00048560 | 01 | PA | AMERICHOICE | OTHER |