1912011321 NPI number — UNIVERSITY OF PENN - ORAL SURGERY ASSOCIATES

Table of content: (NPI 1912011321)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912011321 NPI number — UNIVERSITY OF PENN - ORAL SURGERY ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY OF PENN - ORAL SURGERY ASSOCIATES
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:
1912011321
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3624 MARKET ST
Provider Second Line Business Mailing Address:
SUITE 560W
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19104-2614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-662-2286
Provider Business Mailing Address Fax Number:
215-615-0500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 SPRUCE ST
Provider Second Line Business Practice Location Address:
5 WHITE BUILDING
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:
215-662-3580
Provider Business Practice Location Address Fax Number:
215-662-7445
Provider Enumeration Date:
08/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSTON
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
215-662-7583

Provider Taxonomy Codes

  • Taxonomy code: 204E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0060894000 . This is a "KEYSTONE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7417705 . This is a "NJ MEDICAID" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1008672 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 181611 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 119663 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0019334710 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2Y20463 . This is a "HEALTHNET" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 07658 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: CA2596 . This is a "RR MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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