Organization
TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ELIZABETH JOHNSTON (EXECUTIVE DIRECTOR)
(215) 662-7583
Entity
Organization
Contact information
Practice address
240 S 40TH ST, PHILADELPHIA, PA 19104-6030
(215) 898-5344
(215) 898-3139
Mailing address
3624 MARKET ST, SUITE 560W, PHILADELPHIA, PA 19104-2614
(215) 662-2286
Taxonomy
Speciality
Code
Description
License number
State
204E00000X
Oral & Maxillofacial Surgery (D.M.D.)
Primary
—
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1001258770
—
PA
01
—
1674675
BLUE SHIELD
PA
01
—
2349332000
KEYSTONE
PA
01
—
30015487
KEYSTONE MERCY
PA
01
—
34461
HEALTHPARTNERS
PA
01
—
3537018
AETNA
PA
01
—
DD5746
RAILROAD MEDICARE
PA
Enumeration date
03/28/2007
Last updated
08/22/2020
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