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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
3737 MARKET ST FL 12, PHILADELPHIA, PA 19104-5545
(215) 662-8730
(215) 294-9032
Mailing address
3400 SPRUCE ST, 210 BLDG, PHILADELPHIA, PA 19104-4206
(215) 662-2638
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
—
PA
207RE0101X
Endocrinology, Diabetes & Metabolism Physician
—
PA
207RN0300X
Nephrology Physician
Primary
—
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0002Y20116
HEALTHNET
PA
05
—
0006610360
—
PA
01
—
0176009000
KEYSTONE
PA
01
—
020255499
EEIOC
PA
01
—
1010964
MERCY
PA
01
—
10791
HEALTHPARTNERS
PA
01
—
140770
BLUE SHIELD
PA
01
—
273252
MAMSI
PA
01
—
496714
AETNA
PA
01
—
5484103
NJ-MEDICAID
NJ
01
—
CA0235
RR MEDICARE
PA
01
—
G00031680
AMERICHOICE
PA
Enumeration date
08/17/2006
Last updated
06/12/2025
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