=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649384579
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2006
-----------------------------------------------------
Last Update Date | 05/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 KING OF PRUSSIA RD
-----------------------------------------------------
City | RADNOR
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19087-5220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-902-2000
-----------------------------------------------------
Fax | 610-902-2040
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3624 MARKET ST SUITE 560 W
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-2614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-662-2286
-----------------------------------------------------
Fax | 215-615-0500
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | ELIZABETH JOHNSTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-662-7583
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------