Provider Demographics
NPI:1386765857
Name:UNIV OF PENN - OB-GYN
Entity type:Organization
Organization Name:UNIV OF PENN - OB-GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-662-7583
Mailing Address - Street 1:3624 MARKET ST
Mailing Address - Street 2:SUITE 560W
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2614
Mailing Address - Country:US
Mailing Address - Phone:215-662-2286
Mailing Address - Fax:
Practice Address - Street 1:800 WALNUT ST
Practice Address - Street 2:10TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5109
Practice Address - Country:US
Practice Address - Phone:215-829-2345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207V00000X, 207VX0201X, 261QA0005X, 261QA0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
No261QA0006XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Fertility FacilityGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012026OtherKEYSTONE MERCY
NJ7298609Medicaid
PA0052759000OtherKEYSTONE
PA065511OtherBLUE SHIELD
PA1007448840Medicaid
PA921502OtherAETNA
PACG4675OtherRAILROAD MEDICARE
PA2Y21658OtherHEALTHNET
PA065511OtherBLUE SHIELD