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, 4 DULLES, PHILADELPHIA, PA 19104-4238
(215) 349-8310
Mailing address
3400 SPRUCE ST, 4 DULLES, PHILADELPHIA, PA 19104-4238
(215) 349-8310
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
—
PA
207LC0200X
Critical Care Medicine (Anesthesiology) Physician
Primary
—
PA
207LP2900X
Pain Medicine (Anesthesiology) Physician
—
PA
Other
Enumeration date
12/23/2014
Last updated
11/19/2020
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