1376717538 NPI number — JEFFERSON UNIVERSITY PHYSICIANS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376717538 NPI number — JEFFERSON UNIVERSITY PHYSICIANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFERSON UNIVERSITY PHYSICIANS
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:
FAMILY MEDICINE - SENIOR CENTER
Provider Other Organization Name Type Code:
5
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:
1376717538
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 MARKET ST FL 30
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:
19107-2934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-955-1175
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33 S 9TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19107-4408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-955-6664
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RISTAS
Authorized Official First Name:
HRISTOS
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF PROVIDER OPERATIONS
Authorized Official Telephone Number:
215-955-9298

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30025703 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0060238007 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2977562 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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