Healthcare Provider Details

I. General information

NPI: 1902269210
Provider Name (Legal Business Name): UNIVERSITY OF PENN-MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 N DUKE ST 3RD FLOOR
LANCASTER PA
17602-2225
US

IV. Provider business mailing address

554 N DUKE ST 3RD FLOOR
LANCASTER PA
17602-2225
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StatePA

VIII. Authorized Official

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