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, 1ST FLOOR, PHILADELPHIA, PA 19104-5127
(215) 662-2454
Mailing address
3400 CIVIC CENTER BLVD, 1ST FLOOR, PHILADELPHIA, PA 19104-5127
(215) 662-2454
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
—
PA
207RR0500X
Rheumatology Physician
Primary
—
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0002Y20116
HEALTHNET
PA
05
—
0006610360
—
PA
01
—
020255499
EEIOC
PA
01
—
0276505000
KEYSTONE
PA
01
—
1010975
MERCY
PA
01
—
140756
BLUE SHIELD
PA
01
—
273257
MAMSI
PA
01
—
31848
HEALTHPARTNERS
PA
01
—
496695
AETNA
PA
01
—
5443300
NJ-MEDICAID
NJ
01
—
CA0235
RR MEDICARE
PA
01
—
G00048560
AMERICHOICE
PA
Enumeration date
08/16/2006
Last updated
11/20/2020
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