Provider Demographics
NPI:1134856867
Name:PENN PRESBYTERIAN MEDICAL CENTER OF THE UNIVERSITY OF PENNSYLVANIA HEA
Entity type:Organization
Organization Name:PENN PRESBYTERIAN MEDICAL CENTER OF THE UNIVERSITY OF PENNSYLVANIA HEA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE EXECUTIVE DIRECTOR/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-662-9108
Mailing Address - Street 1:51 N 39TH STREET
Mailing Address - Street 2:CUPP BASEMENT -PHARMACY
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-662-8213
Mailing Address - Fax:215-243-4644
Practice Address - Street 1:51 N 39TH STREET
Practice Address - Street 2:MUTCH BUILDING-OUTPATIENT PHARMACY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-662-9496
Practice Address - Fax:215-243-4671
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENN PRESBYTERIAN MEDICAL CENTER OF THE UNIVERSITY OF PENNSYLVANIA HEA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007297070029Medicaid