# UNIVERSITY OF PENN - MEDICAL GROUP

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

## Provider details

- **NPI number:** 1568579266
- **Authorized official:** CHANTE L JACKSON (ENROLLMENT LEAD)
- **Authorized official phone:** (215) 662-6187

## Contact information

- **Practice address:** 3400 SPRUCE ST, 1 MALONEY, PHILADELPHIA, PA 19104-4206
- **Practice address phone:** (215) 662-2300
- **Mailing address:** 3400 MARKET ST, 1 MALONEY BLDG, PHILADELPHIA, PA 19104-3306

## Taxonomy

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

## Other

- **Enumeration date:** 08/25/2006
- **Last updated:** 11/19/2020

## 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 |