1083720403 NPI number — TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083720403 NPI number — TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA

Employer Identification Number (EIN):

Provider Organization Name:

TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1083720403

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

06/03/2008

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

3624 MARKET ST

Provider Second Line Business Mailing Address:

SUITE 560W

Provider Business Mailing Address City Name:

PHILADELPHIA

Provider Business Mailing Address State Name:

PA

Provider Business Mailing Address Postal Code:

19104-2614

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

215-662-2286

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

250 KING OF PRUSSIA RD

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

RADNOR

Provider Business Practice Location Address State Name:

PA

Provider Business Practice Location Address Postal Code:

19087-5220

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

610-902-2000

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

08/21/2006

Authorized Official Last Name:

JOHNSTON

Authorized Official First Name:

ELIZABETH

Authorized Official Middle Name:

Authorized Official Title or Position:

EXECUTIVE DIRECTOR

Authorized Official Telephone Number:

215-662-7583

• Taxonomy code: 207Q00000X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207QG0300X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 207RG0300X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 732227 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: CN3127 . This is a "RR MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 096188 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 18041 . This is a "HEALTHPARTERNS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 1001258770 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
• Identifier: 1041746 . This is a "MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 2Y21509 . This is a "HEALTHNET" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 8696501 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
• Identifier: 0143087001 . This is a "KEYSTONE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".