=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659488351
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY OF PENN - MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2006
-----------------------------------------------------
Last Update Date | 11/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3737 MARKET ST 3RD FLOOR
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-5545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-662-2775
-----------------------------------------------------
Fax | 215-615-5055
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3624 MARKET ST SUITE 560W
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-2614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-662-2286
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ENROLLMENT LEAD
-----------------------------------------------------
Name | CHANTE L JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-662-6187
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207KA0200X
-----------------------------------------------------
Taxonomy Name | Allergy Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207K00000X
-----------------------------------------------------
Taxonomy Name | Allergy & Immunology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------