Healthcare Provider Details

I. General information

NPI: 1043800667
Provider Name (Legal Business Name): TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 S 40TH ST
PHILADELPHIA PA
19104-6030
US

IV. Provider business mailing address

240 S 40TH ST
PHILADELPHIA PA
19104-6030
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

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