NPIMap

Organization Active NPI

University of Penn-Medical Group

  • Radiation Oncology Physician
  • Philadelphia, PA
National Provider Identifier
1467840488
Registry record updated Nov 19, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Radiation Oncology PhysicianTaxonomy code 2085R0001X
Legal business name
UNIVERSITY OF PENN-MEDICAL GROUP
Practice address
3400 Civic Center Blvd
Concourse Level
Philadelphia, PA 19104-5127
Phone
(215) 662-2428
NPI assigned
Dec 29, 2014
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 19, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Chante L Jackson
Title
Enrollment Lead
Phone
(215) 662-6187

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Radiation Oncology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2085R0001X PA Primary

Addresses

Primary practice location

3400 Civic Center Blvd
Concourse Level
Philadelphia, PA 19104-5127

Mailing address

3400 Civic Center Blvd
Concourse Level
Philadelphia, PA 19104-5127
Phone (215) 662-2428

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other Cobius Healthcare Solutions

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20141111000091 PA Part B Supplier - Clinic/Group Practice 6204730955 Receives reassigned benefits from 3,792 practitioners
47 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment

Other NPIs on the same Medicare enrollment 47

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 47

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 90

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 90

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1419811200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1605744000000",
    "number": "1467840488",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3400 CIVIC CENTER BLVD",
            "address_2": "CONCOURSE LEVEL",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191045127",
            "telephone_number": "215-662-2428"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3400 CIVIC CENTER BLVD",
            "address_2": "CONCOURSE LEVEL",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191045127",
            "telephone_number": "215-662-2428"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "UNIVERSITY OF PENN-MEDICAL GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-12-29",
        "last_updated": "2020-11-19",
        "certification_date": "2020-11-19",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "CHANTE",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "ENROLLMENT LEAD",
        "authorized_official_telephone_number": "215-662-6187"
    },
    "taxonomies": [
        {
            "code": "2085R0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Radiology, Radiation Oncology",
            "state": "PA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.1068.1",
            "affiliationName": "Cobius Healthcare Solutions",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "2720 Dundee Rd # 302",
            "city": "Northbrook",
            "state": "IL",
            "country_code": "US",
            "postal_code": "600622609",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Philadelphia, PA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 19, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.