Provider Demographics
NPI:1881707842
Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Entity type:Organization
Organization Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-662-7583
Mailing Address - Street 1:3624 MARKET ST
Mailing Address - Street 2:SUITE 560 W
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2614
Mailing Address - Country:US
Mailing Address - Phone:215-662-2286
Mailing Address - Fax:215-615-0500
Practice Address - Street 1:51 N 39TH ST
Practice Address - Street 2:7 FLOOR-MUTCH BLDG.
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2640
Practice Address - Country:US
Practice Address - Phone:215-662-8777
Practice Address - Fax:215-243-3290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207R00000X, 207Q00000X
207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7269102OtherNJ-MEDICAID
PA770344OtherAETNA
PACG7756OtherRR MEDICARE
PA0002Y20112OtherHEALTHNET
PA0361490001OtherKEYSTONE
PA1001258770Medicaid
PA902832OtherBLUE SHIELD
PA1043286OtherMERCY
PA300654OtherEEIOC
PA18871OtherHEALTHPARTNERS
PA273885OtherMAMSI
PAG00015990OtherAMERICHOICE
PA902832LXWMedicare ID - Type Unspecified