Provider Demographics
NPI:1083720403
Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Entity Type:Organization
Organization Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
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 1:250 KING OF PRUSSIA RD
Practice Address - Street 2:
Practice Address - City:RADNOR
Practice Address - State:PA
Practice Address - Zip Code:19087-5220
Practice Address - Country:US
Practice Address - Phone:610-902-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207Q00000X, 207QG0300X, 207RG0300X
207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA732227OtherAETNA
PACN3127OtherRR MEDICARE
PA096188OtherBLUE SHIELD
PA18041OtherHEALTHPARTERNS
PA1001258770Medicaid
PA1041746OtherMERCY
PA2Y21509OtherHEALTHNET
NJ8696501Medicaid
PA0143087001OtherKEYSTONE
PA18041OtherHEALTHPARTERNS