Healthcare Provider Details

I. General information

NPI: 1972607257
Provider Name (Legal Business Name): TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE ST 8 RAVDIN
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: 215-662-3228
  • Fax: 215-349-8831
Mailing address:
  • Phone: 215-662-2286
  • Fax: 215-615-0500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH JOHNSTON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 215-662-7583