Provider Demographics
NPI:1487767422
Name:UNIV OF PENN-OTORHINOLARYNGOLOGY
Entity type:Organization
Organization Name:UNIV OF PENN-OTORHINOLARYNGOLOGY
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 1:3400 SPRUCE ST
Practice Address - Street 2:5 SILVERSTEIN
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-2777
Practice Address - Fax:215-662-4613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207YX0007X, 207YX0602X, 207YX0901X, 207YS0123X
PA207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Multi-Specialty
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Multi-Specialty
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Multi-Specialty
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA099961OtherAETNA
NJ7526105OtherNJ-MEDICAID
PA0016786460Medicaid
PA520160OtherBLUE SHIELD
PACN0179OtherRR MEDICARE
PA0111428000OtherKEYSTONE
PAG00031410OtherAMERICHOICE
PA209916800OtherACS
PA1002205OtherMERCY
PA103681OtherHEALTHPARTNERS
PA0002Y21659OtherHEALTHNET
PA203652OtherEEIOC
PA273501OtherMAMSI
NJ7526105OtherNJ-MEDICAID