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
51 N 39TH ST, MOB SUITE 120, PHILADELPHIA, PA 19104-2640
(215) 662-7320
Mailing address
51 N 39TH ST, MOB SUITE 120, PHILADELPHIA, PA 19104-2640
(215) 662-7320
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
—
PA
2086S0102X
Surgical Critical Care Physician
—
PA
2086S0127X
Trauma Surgery Physician
—
PA
Other
Enumeration date
12/29/2014
Last updated
11/19/2020
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