Provider Demographics
NPI:1679544803
Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Entity type:Organization
Organization Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AVP OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:215-762-0888
Mailing Address - Street 1:1500 MARKET ST
Mailing Address - Street 2:UM600
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-2100
Mailing Address - Country:US
Mailing Address - Phone:215-796-4640
Mailing Address - Fax:609-770-7792
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-796-4640
Practice Address - Fax:609-770-7792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0001043000OtherINDEPENDENCE BLUE CROSS
NJ4193105Medicaid
PA1001258770126Medicaid
PA39S111Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER