Healthcare Provider Details

I. General information

NPI: 1396416251
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: 09/21/2021
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E MARSHALL ST
WEST CHESTER PA
19380-4412
US

IV. Provider business mailing address

301 S 7TH AVE
WEST READING PA
19611-1410
US

V. Phone/Fax

Practice location:
  • Phone: 610-431-5000
  • Fax:
Mailing address:
  • Phone: 215-662-6200
  • Fax: 215-615-1298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHANTE L JACKSON
Title or Position: PAYER SUPERVISOR
Credential:
Phone: 215-662-6187