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, GROUND FLOOR DULLES, PHILADELPHIA, PA 19104-4238
(215) 662-3005
Mailing address
3400 SPRUCE ST, GROUND FLOOR DULLES, PHILADELPHIA, PA 19104-4238
(215) 662-3005
Taxonomy
Speciality
Code
Description
License number
State
207U00000X
Nuclear Medicine Physician
—
PA
2085N0700X
Neuroradiology Physician
—
PA
2085N0904X
Nuclear Radiology Physician
—
PA
2085P0229X
Pediatric Radiology Physician
—
PA
2085R0202X
Diagnostic Radiology Physician
Primary
—
PA
2085R0204X
Vascular & Interventional Radiology Physician
—
PA
Other
Enumeration date
12/29/2014
Last updated
11/19/2020
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