1861666174 NPI number — JEFFERSON UNIVERSITY PHYSICIAN

Table of content: (NPI 1861666174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861666174 NPI number — JEFFERSON UNIVERSITY PHYSICIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFERSON UNIVERSITY PHYSICIAN
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:
SURGERY
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:
1861666174
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
833 CHESTNUT ST
Provider Second Line Business Mailing Address:
SUITE 630
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19107-4414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
833 CHESTNUT ST
Provider Second Line Business Practice Location Address:
SUITE 630
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19107-4414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-955-0800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OGUNKEYE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
215-955-2562

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7512007 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1153258 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7531303 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7535805 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1153629 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2678933000 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7531401 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8455708 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7551703 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1153628 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1153665 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1156151 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1153651 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1821657 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 507462 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7550405 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7585403 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1062654 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1153656 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".