Healthcare Provider Details

I. General information

NPI: 1114031036
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: 01/06/2014
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: 610-902-5600
  • Fax:
Mailing address:
  • Phone: 215-662-2286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1001258770
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier2Y21509
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHEALTHNET
# 3
Identifier17588
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHEALTHPARTNERS
# 4
IdentifierCN3127
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerRR MEDICARE
# 5
Identifier707804
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAETNA
# 6
Identifier0211219000
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerKEYSTONE
# 7
Identifier1038515
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerMERCY
# 8
Identifier536910
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE SHIELD

VIII. Authorized Official

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