Provider Demographics
NPI:1295706422
Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Entity type:Organization
Organization Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AVP OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:215-762-0630
Mailing Address - Street 1:1500 MARKET ST
Mailing Address - Street 2:UPPER MEZZANINE 600
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-2100
Mailing Address - Country:US
Mailing Address - Phone:215-762-0630
Mailing Address - Fax:215-762-0630
Practice Address - Street 1:1800 LOMBARD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-8400
Practice Address - Country:US
Practice Address - Phone:215-893-7246
Practice Address - Fax:215-893-7246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0001043000OtherINDEPENDENCE BLUE CROSS
PA1001258770211Medicaid
NJ4193105Medicaid
PA0001043000OtherINDEPENDENCE BLUE CROSS
NJ4193105Medicaid