Healthcare Provider Details

I. General information

NPI: 1720553001
Provider Name (Legal Business Name): UNIVERSITY OF PENN - MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2018
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4923 STANTON OGLETOWN RD
NEWARK DE
19713-2081
US

IV. Provider business mailing address

PO BOX 824320
PHILADELPHIA PA
19182-4320
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-6200
  • Fax: 215-662-2244
Mailing address:
  • Phone: 215-662-6187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHANTE L JACKSON
Title or Position: ENROLLMENT COOR
Credential:
Phone: 215-662-6187