MEDICARE: THOMAS JEFFERSON UNIVERSITY PSYCH

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578723839
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THOMAS JEFFERSON UNIVERSITY PSYCH

Provider Business Mailing Address
First Line	:	833 CHESTNUT ST STE 630
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-4416
Country	:	US
Telephone Number	:	215-955-0800
Fax Number	:

Provider Business Practice Location Address
First Line	:	833 CHESTNUT ST STE 630
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-4416
Country	:	US
Telephone Number	:	215-955-0800
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. JOHN OGUNKEYE
Credential	:
Telephone Number	:	215-955-2562

Provider Enumeration Date	:	06/11/2008
Last Update Date	:	06/11/2008

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