Healthcare Provider Details

I. General information

NPI: 1336304062
Provider Name (Legal Business Name): PENNSYLVANIA HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 SOUTH ST
PHILA PA
19146-7411
US

IV. Provider business mailing address

1500 MARKET ST UPPER MEZZENINE 600
PHILA PA
19102-2100
US

V. Phone/Fax

Practice location:
  • Phone: 215-762-0630
  • Fax: 215-762-0754
Mailing address:
  • Phone: 215-762-0630
  • Fax: 215-762-0754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. THOMAS MCCORMICK
Title or Position: AVP OF FINANCE
Credential:
Phone: 215-762-0888