Healthcare Provider Details

I. General information

NPI: 1013582840
Provider Name (Legal Business Name): PENN MEDICINE-PMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 EGYPT RD
AUDUBON PA
19403-2302
US

IV. Provider business mailing address

150 MONUMENT RD
BALA CYNWYD PA
19004-1702
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: CHANTE JACKSON
Title or Position: PAYER SUPERVISOR
Credential:
Phone: 267-207-7303