Provider Demographics
NPI:1083602908
Name:TEMPLE UNIVERSITY OF THE COMMONWEALTH OF HIGHER EDUCATION
Entity Type:Organization
Organization Name:TEMPLE UNIVERSITY OF THE COMMONWEALTH OF HIGHER EDUCATION
Other - Org Name:TEMPLE DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:KUPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-707-7551
Mailing Address - Street 1:3425 N CARLISLE ST
Mailing Address - Street 2:2ND FL HUDSON BUILDING
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-5108
Mailing Address - Country:US
Mailing Address - Phone:215-707-4739
Mailing Address - Fax:215-707-3677
Practice Address - Street 1:3509 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-4105
Practice Address - Country:US
Practice Address - Phone:215-707-6613
Practice Address - Fax:215-707-6629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000678893001Medicaid
PA1000678893001Medicaid