Provider Demographics
NPI:1003923707
Name:UNIVERSITY OF PENN - MEDICAL GROUP
Entity Type:Organization
Organization Name:UNIVERSITY OF PENN - MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENROLLMENT LEAD
Authorized Official - Prefix:
Authorized Official - First Name:CHANTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-662-6187
Mailing Address - Street 1:3400 SPRUCE ST
Mailing Address - Street 2:3 RAVDIN - SUITE F
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-3202
Mailing Address - Fax:215-349-8432
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:3 RAVDIN, SUITE F, PULMONARY & CRITICAL CARE
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-3202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010943OtherMERCY
PA002Y20116OtherHEALTHNET
PA020255499OtherEEIOC
NJ5469406OtherNJ-MEDICAID
PA06632OtherHEALTHPARTNERS
PAG00031670OtherAMERICHOICE
PA273248OtherMAMSI
PACA0235OtherRR MEDICARE
PA0006610360Medicaid
PA0193436000OtherKEYSTONE
PA043063OtherBLUE SHIELD
PA495710OtherAETNA
PAG00031670OtherAMERICHOICE