MEDICARE: UNIV OF PENN COMMUNITY RADIOLOGY

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207U00000X	Nuclear Medicine Physician
2	2085N0700X	Neuroradiology Physician
3	2085P0229X	Pediatric Radiology Physician
4	2085R0204X	Vascular & Interventional Radiology Physician
5	2085R0202X	Diagnostic Radiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	548327	OTHER	PA	CIGNA
2	705030	OTHER	PA	BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	33158	OTHER	PA	MERCY
6	548327	OTHER	PA	AETNA
7	31072	OTHER	PA	HEALTHPARTNERS
8	0002Y22562	OTHER	PA	HEALTHNET
9	0794791000	OTHER	PA	KEYSTONE

General Provider Information

NPI Number	:	1740293232
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIV OF PENN COMMUNITY RADIOLOGY

Provider Business Mailing Address
First Line	:	3624 MARKET ST
Second Line	:	SUITE 560W
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-2614
Country	:	US
Telephone Number	:	215-662-3958
Fax Number	:	215-615-0500

Provider Business Practice Location Address
First Line	:	999 OLD EAGLE SCHOOL RD
Second Line	:
City	:	WAYNE
State	:	PA
Zip	:	19087-1707
Country	:	US
Telephone Number	:	215-702-3100
Fax Number	:	215-702-3105

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

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	07/15/2011

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