Provider Demographics
NPI:1093989220
Name:JEFFERSON UNIVERSITY PHYSICIANS
Entity Type:Organization
Organization Name:JEFFERSON UNIVERSITY PHYSICIANS
Other - Org Name:INTERNAL MEDICINE- DR PARK
Other - Org Type:Other Name
Authorized Official - Title/Position:VP PROVIDER NETWORK OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:HRISTOS
Authorized Official - Middle Name:
Authorized Official - Last Name:RISTAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-955-9298
Mailing Address - Street 1:PO BOX 828937
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-8937
Mailing Address - Country:US
Mailing Address - Phone:215-503-1240
Mailing Address - Fax:
Practice Address - Street 1:525 W CHESTER PIKE STE 102B
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-4539
Practice Address - Country:US
Practice Address - Phone:610-853-9328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3000370OtherKEYSTONE MERCY
PA0307681005OtherINDEPENDENCE BLUE CROSS
PA595787OtherAETNA