Provider Demographics
NPI:1740278761
Name:TEMPLE UNIVERSITY OF THE COMMONWEALTH SYSTEM OF HIGHER EDUCATION
Entity type:Organization
Organization Name:TEMPLE UNIVERSITY OF THE COMMONWEALTH SYSTEM OF HIGHER EDUCATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-707-3911
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-4000
Mailing Address - Fax:215-707-5066
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:4TH FL AMBULATORY CARE CENTER
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-4000
Practice Address - Fax:215-707-5066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
No261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007780130705Medicaid
719558Medicare ID - Type Unspecified