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 CIVIC CENTER BLVD, WEST PAVILION, 3RD FLOOR SUITE 3-144W, PHILADELPHIA, PA 19104-5127
(215) 614-4100
Mailing address
3400 CIVIC CENTER BLVD, WEST PAVILION, 3RD FLOOR SUITE 3-144W, PHILADELPHIA, PA 19104-5127
(215) 614-4100
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
—
PA
207W00000X
Ophthalmology Physician
Primary
—
PA
Other
Enumeration date
12/26/2014
Last updated
11/19/2020
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