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General NPI Number Information
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NPI Number | 1194829739
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Entity Type | Organization
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Legal Business Name | UNIVERSITY OF PENN - MEDICAL GROUP
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Dates
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Enumeration Date | 09/12/2006
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Last Update Date | 11/19/2020
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Provider Practice Location Address
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Address Line | 3400 SPRUCE ST 11 GATES
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City | PHILADELPHIA
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State | PA
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Zip | 19104-4206
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Country | US
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Telephone | 215-662-7772
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Fax |
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Provider Business Mailing Address
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Address Line | 3400 SPRUCE ST 11 GATES
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City | PHILADELPHIA
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State | PA
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Zip | 19104-4206
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Country | US
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Telephone | 215-662-7772
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Fax |
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Authorized Official
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Title or Position | ENROLLMENT LEAD
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Name | CHANTE L JACKSON
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Credential |
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Telephone | 215-662-6187
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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