Provider Demographics
NPI:1407965031
Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Entity Type:Organization
Organization Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Other - Org Name:UNIV OF PENN - PATHOLOGY & LAB
Other - Org Type:Doing Business As
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:215-662-3958
Mailing Address - Fax:866-586-2431
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-6503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Multi-Specialty
No207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathologyGroup - Multi-Specialty
No207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic PathologyGroup - Multi-Specialty
No207ZP0104XAllopathic & Osteopathic PhysiciansPathologyChemical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1034927OtherKEYSTONE MERCY
PA588106OtherBLUE SHIELD
PA3591047OtherAETNA
PADB3215OtherRAILROAD MEDICARE
PA0410025000OtherKEYSTONE
PA35081OtherHEALTHPARTNERS
PA588106OtherBLUE SHIELD