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General NPI Number Information
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NPI Number | 1316335425
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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 | 12/26/2014
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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 CIVIC CENTER BLVD WEST PAVILION, 3RD FLOOR SUITE 3-144W
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City | PHILADELPHIA
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State | PA
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Zip | 19104-5127
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Country | US
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Telephone | 215-614-4100
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Fax |
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Provider Business Mailing Address
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Address Line | 3400 CIVIC CENTER BLVD WEST PAVILION, 3RD FLOOR SUITE 3-144W
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City | PHILADELPHIA
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State | PA
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Zip | 19104-5127
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Country | US
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Telephone | 215-614-4100
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State | PA
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