Provider Demographics
NPI:1386751089
Name:UNIVERSITY OF PENN-MEDICAL GROUP
Entity type:Organization
Organization Name:UNIVERSITY OF PENN-MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENROLLMENT LEAD
Authorized Official - Prefix:
Authorized Official - First Name:CHANTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-662-6187
Mailing Address - Street 1:51 N 39TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2640
Mailing Address - Country:US
Mailing Address - Phone:215-662-8000
Mailing Address - Fax:
Practice Address - Street 1:51 N 39TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2640
Practice Address - Country:US
Practice Address - Phone:215-662-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006610360Medicaid
PA06638OtherHEALTHPARTNERS
NJ5543509OtherNJ-MEDICAID
PA273200OtherMAMSI
PA40063OtherMERCY
PAG00048520OtherAMERICHOICE
PA0053945000OtherKEYSTONE
PA0002Y20116OtherHEALTHNET
PA147249OtherBLUE SHIELD
PA003473OtherAETNA
PACA0235OtherRR MEDICARE
PACA0235OtherRR MEDICARE