Basic Information
| Provider Information | |||||||||
| NPI: | 1972607257 | ||||||||
| 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: | 3400 SPRUCE ST | ||||||||
| Address2: | 8 RAVDIN | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156623228 | ||||||||
| FaxNumber: | 2153498831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2006 | ||||||||
| LastUpdateDate: | 06/09/2008 | ||||||||
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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 | 207SG0201X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080N0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1001258770 | 05 | PA | MEDICAID | 1013506 | 01 | PA | KEYSTONE MERCY | OTHER | 2Y22674 | 01 | PA | HEATLHNET | OTHER | CI1503 | 01 | PA | RAILROAD MEDICARE | OTHER | 12502 | 01 | PA | HEALTHPARTNERS | OTHER | 0794792000 | 01 | PA | KEYSTONE | OTHER | 502554 | 01 | PA | AETNA | OTHER | 706905 | 01 | PA | BLUE SHIELD | OTHER | 7160402 | 05 | NJ | MEDICAID |