Healthcare Provider Details

I. General information

NPI: 1023373511
Provider Name (Legal Business Name): TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE ST GROUND FLOOR DONNER
PHILADELPHIA PA
19104-4206
US

IV. Provider business mailing address

3624 MARKET ST SUITE 560W
PHILADELPHIA PA
19104-2614
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-6698
  • Fax: 215-662-3953
Mailing address:
  • Phone: 215-662-2286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number StatePA

VIII. Authorized Official

Name: ELIZABETH JOHNSTON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 215-662-7583