1194832899 NPI number — UNIVERSITY OF PENN-MEDICAL GROUP

Table of content: JOSEPH DYMOWSKI (NPI 1659735868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194832899 NPI number — UNIVERSITY OF PENN-MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY OF PENN-MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194832899
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3400 SPRUCE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19104-4206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-662-6932
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 SPRUCE ST
Provider Second Line Business Practice Location Address:
3 SILVERSTEIN BUILDING, SUITE D
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-4206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-662-6932
Provider Business Practice Location Address Fax Number:
215-662-7899
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
CHANTE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
ENROLLMENT LEAD
Authorized Official Telephone Number:
215-662-6187

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2080P0208X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0002Y20116 . This is a "HEALTHNET" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 043054 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1010882 . This is a "MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 496686 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 10724 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 5467403 . This is a "NJ-MEDICAID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: CA0235 . This is a "RR MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0345789000 . This is a "KEYSTONE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0006610360 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 273224 . This is a "MAMSI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: G00048530 . This is a "AMERICHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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