MEDICARE: TRUSTEES OF THE UNIV OF PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207SG0203X	Clinical Molecular Genetics Physician
2	207SG0205X	Ph.D. Medical Genetics Physician
3	207SM0001X	Molecular Genetic Pathology (Medical Genetics) Physician
4	207SG0201X	Clinical Genetics (M.D.) Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
7	CN3127	OTHER	PA	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1130183	OTHER	PA	MERCY
2	708403	OTHER	PA	AETNA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	17609	OTHER	PA	HEALTHPARTERNS
5	2Y21509	OTHER	PA	HEALTHNET
6	0143087000	OTHER	PA	KEYSTONE
8	666274	OTHER	PA	BLUE SHIELD

General Provider Information

NPI Number	:	1508972928
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRUSTEES OF THE UNIV OF PA

Provider Business Mailing Address
First Line	:	3624 MARKET ST
Second Line	:	SUITE 560W
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-2614
Country	:	US
Telephone Number	:	215-662-2286
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 KING OF PRUSSIA RD
Second Line	:
City	:	RADNOR
State	:	PA
Zip	:	19087-5220
Country	:	US
Telephone Number	:	610-902-2000
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	ELIZABETH JOHNSTON
Credential	:
Telephone Number	:	215-662-7583

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	05/09/2008

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