Provider Demographics
NPI:1992824312
Name:THOMAS JEFFERSON UNIVERSITY
Entity Type:Organization
Organization Name:THOMAS JEFFERSON UNIVERSITY
Other - Org Name:JEFFERSON UNIV-MATER FAMILY CENTER
Other - Org Type:Other Name
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
Mailing Address - Street 2:SUITE 401
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5453
Mailing Address - Country:US
Mailing Address - Phone:215-955-1952
Mailing Address - Fax:215-568-6414
Practice Address - Street 1:1233 LOCUST ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5453
Practice Address - Country:US
Practice Address - Phone:215-955-1952
Practice Address - Fax:215-568-6414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAN8LT6601261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007571300103Medicaid