Provider Demographics
NPI:1285022202
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:EMROLLMENT LEAD
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 1:3737 MARKET ST
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5545
Mailing Address - Country:US
Mailing Address - Phone:215-662-8777
Mailing Address - Fax:
Practice Address - Street 1:3737 MARKET ST
Practice Address - Street 2:9TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5545
Practice Address - Country:US
Practice Address - Phone:215-662-8777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-29
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty