Provider Demographics
NPI:1043670805
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 1:554 N DUKE ST
Mailing Address - Street 2:3RD FLOOR GI TRANSPLANT
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2225
Mailing Address - Country:US
Mailing Address - Phone:215-662-6200
Mailing Address - Fax:215-662-2244
Practice Address - Street 1:554 N DUKE ST
Practice Address - Street 2:3RD FLOOR GI TRANSPLANT
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2225
Practice Address - Country:US
Practice Address - Phone:215-662-6200
Practice Address - Fax:215-662-2244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207RG0100X, 2086S0129X, 204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant SurgeryGroup - Multi-Specialty
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty