Provider Demographics
NPI:1992788350
Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Entity type:Organization
Organization Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:I
Authorized Official - Last Name:REDMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-992-3985
Mailing Address - Street 1:625 CLARK AVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-1438
Mailing Address - Country:US
Mailing Address - Phone:610-992-3920
Mailing Address - Fax:610-265-7427
Practice Address - Street 1:625 CLARK AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-1438
Practice Address - Country:US
Practice Address - Phone:610-992-3920
Practice Address - Fax:610-265-7427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 251F00000X, 332BP3500X
PAPP414860L3336C0003X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
No251E00000XAgenciesHome Health
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1001258770182Medicaid
PA1001258770270Medicaid
PA0389970002Medicare NSC
PA1001258770182Medicaid