1972607257 NPI number — TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972607257 NPI number — TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA

Employer Identification Number (EIN):

Provider Organization Name:

TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

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:

1972607257

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

06/09/2008

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

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 First Line Business Practice Location Address:

3400 SPRUCE ST

Provider Second Line Business Practice Location Address:

8 RAVDIN

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:

215-662-3228

Provider Business Practice Location Address Fax Number:

215-349-8831

Provider Enumeration Date:

09/08/2006

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

• Taxonomy code: 207SG0201X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2080N0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 2080P0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 1001258770 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
• Identifier: 1013506 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 2Y22674 . This is a "HEATLHNET" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: CI1503 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 12502 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 0794792000 . This is a "KEYSTONE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 502554 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 706905 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 7160402 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".