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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
51 N 39TH ST, PHILADELPHIA, PA 19104-2640
(215) 662-8000
Mailing address
51 N 39TH ST, PHILADELPHIA, PA 19104-2640
(215) 662-8000
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0002Y20116
HEALTHNET
PA
05
—
0006610360
—
PA
01
—
003473
AETNA
PA
01
—
0053945000
KEYSTONE
PA
01
—
06638
HEALTHPARTNERS
PA
01
—
147249
BLUE SHIELD
PA
01
—
273200
MAMSI
PA
01
—
40063
MERCY
PA
01
—
5543509
NJ-MEDICAID
NJ
01
—
CA0235
RR MEDICARE
PA
01
—
G00048520
AMERICHOICE
PA
Enumeration date
08/25/2006
Last updated
11/19/2020
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