Provider Demographics
NPI:1629181912
Name:UNIVERSITY OF PENN - MEDICAL GROUP
Entity type:Organization
Organization Name:UNIVERSITY OF PENN - MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENROLLMENT LEAD
Authorized Official - Prefix:
Authorized Official - First Name:CHANTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-662-6187
Mailing Address - Street 1:3400 SPRUCE ST
Mailing Address - Street 2:210 BLDG
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-2638
Mailing Address - Fax:
Practice Address - Street 1:3737 MARKET ST FL 12
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5545
Practice Address - Country:US
Practice Address - Phone:215-662-8730
Practice Address - Fax:215-294-9032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207R00000X, 207RE0101X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5484103OtherNJ-MEDICAID
PA0002Y20116OtherHEALTHNET
PA0006610360Medicaid
PA10791OtherHEALTHPARTNERS
PA273252OtherMAMSI
PACA0235OtherRR MEDICARE
PAG00031680OtherAMERICHOICE
PA020255499OtherEEIOC
PA140770OtherBLUE SHIELD
PA496714OtherAETNA
PA1010964OtherMERCY
PA0176009000OtherKEYSTONE
PA140770Medicare PIN