Healthcare Provider Details

I. General information

NPI: 1699889501
Provider Name (Legal Business Name): TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 KING OF PRUSSIA RD
RADNOR PA
19087-5220
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 610-902-2000
  • Fax:
Mailing address:
  • Phone: 215-662-2286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

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