Provider Demographics
NPI:1659488351
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 1:3624 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:
Practice Address - Street 1:3737 MARKET ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5545
Practice Address - Country:US
Practice Address - Phone:215-662-2775
Practice Address - Fax:215-615-5055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207K00000X, 207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA496665OtherAETNA
PA043057OtherBLUE SHIELD
PA5464404OtherNJ-MEDICAID
PACA0235OtherRR MEDICARE
PA273538OtherMAMSI
PA145644000OtherKEYSTONE
PA0006610360Medicaid
PAG00108940OtherAMERICHOICE
PA0002Y20116OtherHEALTHNET
PA1008657OtherMERCY
PA06631OtherHEALTHPARTNERS
PA5464404OtherNJ-MEDICAID