Provider Demographics
NPI:1174511273
Name:TEMPLE UNIVERSITY OF THE COMMONWEALTH SYSTEM OF HIGHER EDUCATION
Entity Type:Organization
Organization Name:TEMPLE UNIVERSITY OF THE COMMONWEALTH SYSTEM OF HIGHER EDUCATION
Other - Org Name:TEMPLE PLASTIC SURGERY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER, CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-707-3911
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-3933
Mailing Address - Fax:215-707-2531
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140
Practice Address - Country:US
Practice Address - Phone:215-707-3933
Practice Address - Fax:215-707-2531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007780130782Medicaid
PA1007780130781Medicaid
PA1007780130780Medicaid
PA1007780130776Medicaid
PA1007780130778Medicaid
PA1007780130122Medicaid
PA1007780130777Medicaid
PA1007780130779Medicaid