Provider Demographics
NPI:1497767495
Name:UNIVERSITY OF PENN - MEDICAL GROUP
Entity Type:Organization
Organization Name:UNIVERSITY OF PENN - MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENROLLMENT LEAD
Authorized Official - Prefix:
Authorized Official - First Name:CHANTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-662-6187
Mailing Address - Street 1:3615 RALSTON CENTER
Mailing Address - Street 2:RALSTON PENN CENTER
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3615 CHESTNUT ST
Practice Address - Street 2:RALSTON-PENN CENTER
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2612
Practice Address - Country:US
Practice Address - Phone:215-662-2746
Practice Address - Fax:215-349-5648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010530OtherMERCY
PACA0235OtherRR MEDICARE
PA496703OtherAETNA
PA0006610360Medicaid
NJ5466407OtherNJ-MEDICAID
PA11192OtherHEALTH PARTNERS
PA0002Y20116OtherHEALTHNET
PA0270301000OtherKEYSTONE
PA043052OtherBLUE SHIELD
PA273211OtherMAMSI
PAG0005268OtherAMERICHOICE
PA496703OtherAETNA