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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, 1 MALONEY, PHILADELPHIA, PA 19104-4206
(215) 662-2300
Mailing address
3400 MARKET ST, 1 MALONEY BLDG, PHILADELPHIA, PA 19104-3306
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
—
—
207RE0101X
Endocrinology, Diabetes & Metabolism Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0002Y20116
HEALTHNET
PA
05
—
0006610360
—
PA
01
—
0346863000
KEYSTONE
PA
01
—
1012794
MERCY
PA
01
—
10809
HEALTHPARTNERS
PA
01
—
273188
MAMSI
PA
01
—
496680
AETNA
PA
01
—
5505101
NJ-MEDICAID
NJ
01
—
63533
BLUE SHIELD
PA
01
—
CA0235
RR MEDICARE
PA
01
—
G00031660
AMERICHOICE
PA
Enumeration date
08/25/2006
Last updated
11/19/2020
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