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General NPI Number Information
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NPI Number | 1053576835
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Entity Type | Organization
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Legal Business Name | UPENN LIFE
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Dates
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Enumeration Date | 07/22/2008
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Last Update Date | 07/22/2008
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Provider Practice Location Address
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Address Line | 4508 CHESTNUT ST
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City | PHILADELPHIA
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State | PA
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Zip | 19139-3608
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Country | US
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Telephone | 215-573-7200
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Fax |
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Provider Business Mailing Address
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Address Line | 4508 CHESTNUT ST
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City | PHILADELPHIA
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State | PA
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Zip | 19139-3608
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Country | US
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Telephone | 215-573-7200
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. BRUCE KINOSIAN
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Credential | MD
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Telephone | 215-573-7200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | MD421701
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License Number State | PA
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