Healthcare Provider Details

I. General information

NPI: 1972682995
Provider Name (Legal Business Name): CLINICAL CARE ASSOCIATES OF THE UNIVERSITY OF PENNSYLVANIA HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 KING OF PRUSSIA RD 4TH FLOOR
RADNOR PA
19087-5220
US

IV. Provider business mailing address

250 KING OF PRUSSIA RD 4TH FLOOR
RADNOR PA
19087-5220
US

V. Phone/Fax

Practice location:
  • Phone: 610-902-1720
  • Fax:
Mailing address:
  • Phone: 610-902-1720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

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