Provider Demographics
NPI: | 1790737468 |
---|---|
Name: | CLINICAL CARE ASSOCIATES OF THE UNIVERSITY OF PENNSYLVANIA HEALTH SYST |
Entity Type: | Organization |
Organization Name: | CLINICAL CARE ASSOCIATES OF THE UNIVERSITY OF PENNSYLVANIA HEALTH SYST |
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: | 150 MONUMENT RD FL 4 |
Mailing Address - Street 2: | |
Mailing Address - City: | BALA CYNWYD |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 19004-1702 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 610-239-2871 |
Mailing Address - Fax: | 610-239-2885 |
Practice Address - Street 1: | 150 MONUMENT RD FL 4 |
Practice Address - Street 2: | |
Practice Address - City: | BALA CYNWYD |
Practice Address - State: | PA |
Practice Address - Zip Code: | 19004-1702 |
Practice Address - Country: | US |
Practice Address - Phone: | 610-239-2871 |
Practice Address - Fax: | 610-239-2885 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-05-17 |
Last Update Date: | 2023-08-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
207PE0004X, 207PS0010X, 207R00000X, 207RE0101X, 207RH0002X, 207RI0200X, 207RR0500X, 207RS0012X, 207V00000X, 2084N0400X, 208M00000X, 208M00000X | ||
PA | 207RC0000X, 208600000X, 207T00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
No | 207PE0004X | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | Group - Multi-Specialty |
No | 207PS0010X | Allopathic & Osteopathic Physicians | Emergency Medicine | Sports Medicine | Group - Multi-Specialty |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RH0002X | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | Group - Multi-Specialty |
No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
No | 207RS0012X | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 1343994 | Other | BLUE SHIELD |
PA | 428207 | Other | BLUE SHIELD |
PA | 100730664 | Medicaid | |
PA | 428207 | Medicare PIN |