Provider Demographics
NPI:1962515973
Name:UNIV OF PENN-NEUROSURGERY
Entity type:Organization
Organization Name:UNIV OF PENN-NEUROSURGERY
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 560 W
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:866-586-2431
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:3 SILVERSTEIN
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-3487
Practice Address - Fax:215-349-5534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA118188100OtherACS
PA273496OtherMAMSI
PA055952OtherBLUE SHIELD
PA06713OtherHEALTHPARTNERS
PA093237OtherAETNA
PACG4674OtherRR MEDICARE
PA0052213000OtherKEYSTONE
PA0002Y20049OtherHEALTHNET
PA0007557130Medicaid
NJ4193113OtherNJ-MEDICAID
PA47781OtherMERCY
PAG00031380OtherAMERICHOICE
PA0002Y20049OtherHEALTHNET