Healthcare Provider Details

I. General information

NPI: 1508972928
Provider Name (Legal Business Name): TRUSTEES OF THE UNIV OF PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 05/09/2008
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 Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207SG0203X
TaxonomyClinical Molecular Genetics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207SG0205X
TaxonomyPh.D. Medical Genetics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207SM0001X
TaxonomyMolecular Genetic Pathology (Medical Genetics) Physician
License Number
License Number State

VIII. Authorized Official

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