Provider Demographics
NPI:1912011321
Name:UNIVERSITY OF PENN - ORAL SURGERY ASSOCIATES
Entity Type:Organization
Organization Name:UNIVERSITY OF PENN - ORAL SURGERY ASSOCIATES
Other - Org Name:
Other - Org Type:
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:215-662-2286
Mailing Address - Fax:215-615-0500
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:5 WHITE BUILDING
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-3580
Practice Address - Fax:215-662-7445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0060894000OtherKEYSTONE
NJ7417705OtherNJ MEDICAID
PA1008672OtherKEYSTONE MERCY
PA181611OtherBLUE SHIELD
PA119663OtherAETNA
PA0019334710Medicaid
PA2Y20463OtherHEALTHNET
PA07658OtherHEALTHPARTNERS
PACA2596OtherRR MEDICARE
PACA2596OtherRR MEDICARE