Provider Demographics
NPI:1972622306
Name:THOMAS JEFFERSON UNIVERSITY
Entity Type:Organization
Organization Name:THOMAS JEFFERSON UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CALVANO
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:215-955-1952
Mailing Address - Street 1:1233 LOCUST ST STE 401
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5459
Mailing Address - Country:US
Mailing Address - Phone:215-955-1952
Mailing Address - Fax:215-568-6414
Practice Address - Street 1:1239 SPRING GARDEN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-3206
Practice Address - Country:US
Practice Address - Phone:215-763-1020
Practice Address - Fax:215-763-4640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA800000127261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007571300097Medicaid