Healthcare Provider Details

I. General information

NPI: 1437547544
Provider Name (Legal Business Name): UNIVERSITY OF PENN-MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2014
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 HAMILTON WALK 1 JOHN MORGAN BLDG
PHILADELPHIA PA
19104-4799
US

IV. Provider business mailing address

3620 HAMILTON WALK 1 JOHN MORGAN BLDG
PHILADELPHIA PA
19104-4799
US

V. Phone/Fax

Practice location:
  • Phone: 215-898-9095
  • Fax:
Mailing address:
  • Phone: 215-898-9095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207PH0002X
TaxonomyHospice and Palliative Medicine (Emergency Medicine) Physician
License Number
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number
License Number StatePA

VIII. Authorized Official

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