Provider Demographics
NPI:1053576835
Name:UPENN LIFE
Entity type:Organization
Organization Name:UPENN LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:KINOSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-573-7200
Mailing Address - Street 1:4508 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-3608
Mailing Address - Country:US
Mailing Address - Phone:215-573-7200
Mailing Address - Fax:
Practice Address - Street 1:4508 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-3608
Practice Address - Country:US
Practice Address - Phone:215-573-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UPENN SCHOOL OF NURSING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD421701302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
E66235Medicare UPIN