Healthcare Provider Details

I. General information

NPI: 1508380452
Provider Name (Legal Business Name): CLINICAL CARE ASSOCIATES OF THE UNIVERSITY OF PENNSYLVANIA HEALTH SYST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 SOUTH BROAD ST, UNIT 28 PENN URGENT CARE SOUTH PHILADELPHIA
PHILADELPHIA PA
19145-2328
US

IV. Provider business mailing address

250 KING OF PRUSSIA RD FL 4
RADNOR PA
19087-5235
US

V. Phone/Fax

Practice location:
  • Phone: 215-419-7500
  • Fax: 215-419-7505
Mailing address:
  • Phone: 610-902-1720
  • Fax: 610-902-1789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number
License Number StatePA
# 7
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StatePA
# 9
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State
# 12
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StatePA

VIII. Authorized Official

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