Provider Demographics
NPI:1326154741
Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Entity Type:Organization
Organization Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
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:215-615-0500
Practice Address - Street 1:250 KING OF PRUSSIA RD
Practice Address - Street 2:
Practice Address - City:RADNOR
Practice Address - State:PA
Practice Address - Zip Code:19087-5220
Practice Address - Country:US
Practice Address - Phone:610-902-2000
Practice Address - Fax:610-902-2040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207V00000X, 207VE0102X, 207VG0400X, 207VM0101X, 207VX0000X, 207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1038424OtherMERCY
PAG00020390OtherAMERICHOICE
PA1001258770Medicaid
PA300654OtherEEIOC
PA17975OtherHEALTHPARTNERS
PACN3217OtherRR MEDICARE
PA0002Y21509OtherHEALTHNET
PA706415OtherAETNA
PA096183OtherBLUE SHIELD
PA116472401OtherACS
PA273369OtherMAMSI
PA8718903OtherNJ-MEDICAID
PA0143086000OtherKEYSTONE
PA17975OtherHEALTHPARTNERS