Provider Demographics
NPI:1972682995
Name:CLINICAL CARE ASSOCIATES OF THE UNIVERSITY OF PENNSYLVANIA HEALTH
Entity type:Organization
Organization Name:CLINICAL CARE ASSOCIATES OF THE UNIVERSITY OF PENNSYLVANIA HEALTH
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 1:250 KING OF PRUSSIA RD
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:RADNOR
Mailing Address - State:PA
Mailing Address - Zip Code:19087-5220
Mailing Address - Country:US
Mailing Address - Phone:610-902-1720
Mailing Address - Fax:
Practice Address - Street 1:250 KING OF PRUSSIA RD
Practice Address - Street 2:4TH FLOOR
Practice Address - City:RADNOR
Practice Address - State:PA
Practice Address - Zip Code:19087-5220
Practice Address - Country:US
Practice Address - Phone:610-902-1720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA428207OtherBLUE SHIELD
PA1343994OtherBLUE SHIELD
PA428207Medicare PIN