1790173805 NPI number — UNIVERSITY OF PENN-MEDICAL GROUP

Table of content: DR. LARRY D. STEWART JR. MD (NPI 1285689778)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790173805 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:
1790173805
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2020
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:
3 SILVERSTEIN BUILDING
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19104-4238
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-662-3487
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
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-4238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-662-3487
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/26/2014

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 2085N0700X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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