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Organization
UNIVERSITY OF PENN - MEDICAL GROUP
Active
Organization
UNIVERSITY OF PENN - MEDICAL GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CHANTE L JACKSON (ENROLLMENT LEAD)
(215) 662-6187
Entity
Organization
Contact information
Practice address
3400 SPRUCE ST, 11 GATES, PHILADELPHIA, PA 19104-4206
(215) 662-7772
Mailing address
3400 SPRUCE ST, 11 GATES, PHILADELPHIA, PA 19104-4206
(215) 662-7772
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
—
PA
207R00000X
Internal Medicine Physician
Primary
—
—
207RP1001X
Pulmonary Disease Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0002Y20116
HEALTHNET
PA
01
—
0193436000
KEYSTONE
PA
01
—
020255499
EEIOC
PA
01
—
043063
BLUE SHIELD
PA
05
—
1007317230185
—
PA
01
—
1019356
MERCY
PA
01
—
289562
MAMSI
PA
01
—
32259
HEALTHPARTNERS
PA
05
—
5469406
—
NJ
01
—
783721
AETNA
PA
01
—
CA0235
RR MEDICARE
PA
01
—
G00021180
AMERICHOICE
PA
Enumeration date
09/12/2006
Last updated
11/19/2020
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