Provider Demographics
NPI:1437425360
Name:JEFFERSON UNIVERSITY PHYSICIANS
Entity Type:Organization
Organization Name:JEFFERSON UNIVERSITY PHYSICIANS
Other - Org Name:JUP ANCILLARY PROVIDERS
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNKEYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-955-2562
Mailing Address - Street 1:615 CHESTNUT ST
Mailing Address - Street 2:14TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-4495
Mailing Address - Country:US
Mailing Address - Phone:215-955-9655
Mailing Address - Fax:
Practice Address - Street 1:615 CHESTNUT ST
Practice Address - Street 2:14TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-4495
Practice Address - Country:US
Practice Address - Phone:215-955-9655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA133N00000X, 363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007729870101Medicaid
PA1007729870101Medicaid