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
3737 MARKET ST, 3RD FLOOR, PHILADELPHIA, PA 19104-5545
(215) 662-2775
(215) 615-5055
Mailing address
3624 MARKET ST, SUITE 560W, PHILADELPHIA, PA 19104-2614
(215) 662-2286
Taxonomy
Speciality
Code
Description
License number
State
207K00000X
Allergy & Immunology Physician
Primary
—
PA
207KA0200X
Allergy Physician
—
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0002Y20116
HEALTHNET
PA
05
—
0006610360
—
PA
01
—
043057
BLUE SHIELD
PA
01
—
06631
HEALTHPARTNERS
PA
01
—
1008657
MERCY
PA
01
—
145644000
KEYSTONE
PA
01
—
273538
MAMSI
PA
01
—
496665
AETNA
PA
01
—
5464404
NJ-MEDICAID
PA
01
—
CA0235
RR MEDICARE
PA
01
—
G00108940
AMERICHOICE
PA
Enumeration date
08/25/2006
Last updated
11/19/2020
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