Healthcare Provider Details

I. General information

NPI: 1265518682
Provider Name (Legal Business Name): PRESBYTERIAN MEDICAL CENTER OF THE UNIVERSITY OF PENNSYLVANIA HEALTH S
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 N 39TH STREET, MEDICAL OFFICE BLDG
PHILADELPHIA PA
19104
US

IV. Provider business mailing address

39TH & MARKET STREETS DEPARTMENT OF PHARMACY
PHILA PA
19104-2640
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-9494
  • Fax: 215-243-4681
Mailing address:
  • Phone: 215-662-9494
  • Fax: 215-243-4681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberPP481327
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPP481327
License Number StatePA

VIII. Authorized Official

Name: MR. ROBERT JOHN RUSSELL JR.
Title or Position: ASSOCIATE EXECUTIVE DIRECTOR
Credential:
Phone: 215-662-9108