=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588136055
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFERSON UNIVERSITY PHYSCIANS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2018
-----------------------------------------------------
Last Update Date | 10/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 SANSOM ST FL 10
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-5002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-955-6844
-----------------------------------------------------
Fax | 215-955-2526
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 828937
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19182-8937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-503-1240
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSOCIATE DIRECTOR, CREDENTIALING
-----------------------------------------------------
Name | VALERIE YVETTE BRIGHT-BUTLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-955-9451
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------