Provider Demographics
NPI:1356354559
Name:UNIV OF PENN-UROLOGY
Entity type:Organization
Organization Name:UNIV OF PENN-UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-662-7583
Mailing Address - Street 1:3624 MARKET ST
Mailing Address - Street 2:SUITE 560 W
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2614
Mailing Address - Country:US
Mailing Address - Phone:215-662-2286
Mailing Address - Fax:215-615-0500
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:9 PENN TOWER
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-2891
Practice Address - Fax:215-662-6764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA203679OtherEEIOC
PA273263OtherMAMSI
PA0053471000OtherKEYSTONE
PA06723OtherHEALTHPARTNERS
NJ7557302OtherNJ-MEDICAID
PA1011505OtherMERCY
PA006782OtherAETNA
PA056674OtherBLUE SHIELD
PA1007618490Medicaid
PACA1238OtherRR MEDICARE
PA1007618490Medicaid