# UNIVERSITY OF PENN-MEDICAL GROUP

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1477658599
- **Authorized official:** CHANTE L JACKSON (ENROLLMENT LEAD)
- **Authorized official phone:** (215) 662-6187

## Contact information

- **Practice address:** 3400 SPRUCE ST, 4 PENN TOWER, PHILADELPHIA, PA 19104-4206
- **Practice address phone:** (215) 662-2468
- **Practice address fax:** (215) 349-8529
- **Mailing address:** 3400 SPRUCE ST, 4 PENN TOWER, PHILADELPHIA, PA 19104-4206
- **Mailing address phone:** (215) 662-2468

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207R00000X | Internal Medicine Physician | — | PA | Yes |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | — | PA | — |

## Other

- **Enumeration date:** 09/13/2006
- **Last updated:** 11/19/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0002Y20116 | HEALTHNET | PA |
| 05 | — | 0006610360 | — | PA |
| 01 | — | 0238576000 | KEYSTONE | PA |
| 01 | — | 273544 | MAMSI | PA |
| 01 | — | 30009058 | MERCY | PA |
| 01 | — | 33631 | HEALTHPARTNERS | PA |
| 01 | — | 482524 | BLUE SHIELD | PA |
| 01 | — | 496680 | AETNA | PA |
| 05 | — | 5507103 | — | NJ |
| 01 | — | CA0235 | RR MEDICARE | PA |