Provider Demographics
NPI:1295856771
Name:UNIV OF PENN - OB-GYN
Entity Type:Organization
Organization Name:UNIV OF PENN - OB-GYN
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 1:3400 SPRUCE ST
Practice Address - Street 2:2000 COURTYARD BUILDING
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-2982
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA490662OtherAETNA
NJ7298609Medicaid
PA1012027OtherKEYSTONE MERCY
PA2Y20350OtherHEALTHNET
PADA9430OtherRAILROAD MEDICARE
PA0372782000OtherKEYSTONE
PA273227OtherMAMSI
PA532383OtherBLUE SHIELD
PA1007448840Medicaid
PA25607OtherHEALTHPARTNERS
PA1007448840Medicaid