Provider Demographics
NPI:1003946153
Name:UNIVERSITY OF PENN - DERMATOLOGY
Entity Type:Organization
Organization Name:UNIVERSITY OF PENN - DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENROLLMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-662-7583
Mailing Address - Street 1:3624 MARKET ST
Mailing Address - Street 2:SUITE 560W
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2614
Mailing Address - Country:US
Mailing Address - Phone:215-662-2286
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:2 RHOADS
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-2737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA14945OtherHEALTHPARTNERS
PA2214380000OtherKEYSTONE
PA80939OtherBLUE SHIELD
PACA5541OtherRAILROAD MEDICARE
PA1007486690Medicaid
PA1024157OtherKEYSTONE MERCY
PA1117604OtherAETNA
PA1007486690Medicaid