Provider Demographics
NPI:1932252228
Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Entity Type:Organization
Organization Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Other - Org Name:PENN MEDICINE AT RADNOR ENDOSCOPY FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LEAD COORDINTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHANTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-662-6187
Mailing Address - Street 1:250 KING OF PRUSSIA RD
Mailing Address - Street 2:
Mailing Address - City:RADNOR
Mailing Address - State:PA
Mailing Address - Zip Code:19087-5220
Mailing Address - Country:US
Mailing Address - Phone:610-902-1500
Mailing Address - Fax:
Practice Address - Street 1:250 KING OF PRUSSIA RD
Practice Address - Street 2:
Practice Address - City:RADNOR
Practice Address - State:PA
Practice Address - Zip Code:19087-5220
Practice Address - Country:US
Practice Address - Phone:610-902-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-19
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA1903X
PA1675261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1461OtherINDEPENDENCE BLUE CROSS
PA707804OtherAETNA U S HEALTHCARE
PA707804OtherAETNA U S HEALTHCARE