Provider Demographics
NPI:1356450548
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:215-615-0500
Practice Address - Street 1:801 SPRUCE ST
Practice Address - Street 2:8TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5701
Practice Address - Country:US
Practice Address - Phone:215-829-7201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-06-25
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
PA1007448840Medicaid
PAG00071400OtherAMERICHOICE
PA1012026OtherMERCY
PA2Y21658OtherHEALTHNET
PA27541OtherHEALTHPARTNERS
PA273503OtherMAMSI
PA0052759000OtherKEYSTONE
PA065511OtherBLUE SHIELD
PA921502OtherAETNA
PACG4675OtherRR MEDICARE
PA1012026OtherMERCY