Provider Demographics
NPI:1912014614
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 1:3400 SPRUCE ST
Mailing Address - Street 2:ONE MALONEY
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-4740
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:ONE MALONEY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-4740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0053945000OtherKEYSTONE
PA1061396OtherMERCY
PACA0235OtherRR MEDICARE
PA0002Y20116OtherHEALTHNET
PA147249OtherBLUE SHIELD
PA980167OtherAETNA
PA26256OtherHEALTHPARTNERS
PA273231OtherMAMSI
PA0006610360Medicaid
NJ7768508OtherNJ-MEDICAID
PAG00053120OtherAMERICHOICE
PA980167OtherAETNA