Provider Demographics
NPI:1114481504
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 COOR
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:PO BOX 824320
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-4320
Mailing Address - Country:US
Mailing Address - Phone:215-662-6187
Mailing Address - Fax:866-586-1994
Practice Address - Street 1:1800 LOMBARD ST STE 206
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-1414
Practice Address - Country:US
Practice Address - Phone:215-615-2222
Practice Address - Fax:215-893-7317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-30
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty