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
3615 CHESTNUT ST, RALSTON-PENN CENTER, PHILADELPHIA, PA 19104-2612
(215) 662-2746
(215) 349-5648
Mailing address
3615 RALSTON CENTER, RALSTON PENN CENTER, PHILADELPHIA, PA 19104-2612
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
—
—
207R00000X
Internal Medicine Physician
—
—
207RG0300X
Geriatric Medicine (Internal Medicine) Physician
Primary
—
—
207RP1001X
Pulmonary Disease Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0002Y20116
HEALTHNET
PA
05
—
0006610360
—
PA
01
—
0270301000
KEYSTONE
PA
01
—
043052
BLUE SHIELD
PA
01
—
1010530
MERCY
PA
01
—
11192
HEALTH PARTNERS
PA
01
—
273211
MAMSI
PA
01
—
496703
AETNA
PA
01
—
5466407
NJ-MEDICAID
NJ
01
—
CA0235
RR MEDICARE
PA
01
—
G0005268
AMERICHOICE
PA
Enumeration date
08/12/2006
Last updated
11/19/2020
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