NPIMap

Organization Active NPI

University of Penn-Medical Group

  • Vascular Surgery Physician
  • Philadelphia, PA
National Provider Identifier
1629466644
Registry record updated Nov 19, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Vascular Surgery PhysicianTaxonomy code 2086S0129X
Legal business name
UNIVERSITY OF PENN-MEDICAL GROUP
Practice address
3400 Civic Center Blvd
2 East Pavillion
Philadelphia, PA 19104-5127
Phone
(215) 615-4949
NPI assigned
Dec 29, 2014
Last updated
Nov 19, 2020By the provider in NPPES
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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208600000X PA
Vascular Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2086S0129X PA Primary

Addresses

Primary practice location

3400 Civic Center Blvd
2 East Pavillion
Philadelphia, PA 19104-5127

Mailing address

3400 Civic Center Blvd
2 East Pavillion
Philadelphia, PA 19104-5127
Phone (215) 615-4949

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
Tax ID family
Cobius Healthcare Solutions24 organizations share this tax ID, including this one

Other organizations with this tax ID 23

Organizations that report the same tax identification number in the National Provider Directory.

View all 23

Locations

3400 Civic Center Blvd
Ste 2E
Philadelphia, PA 19104
Phone (215) 615-0820

145 King of Prussia Rd
Ste 111
Radnor, PA 19087
Phone (610) 902-1800

800 Spruce St
William Penn Annex West, PA 19107
Phone (215) 829-3867

Practitioners & affiliated clinicians

Practitioners 41

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 41

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": "1629466644",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3400 CIVIC CENTER BLVD",
            "address_2": "2 EAST PAVILLION",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191045127",
            "telephone_number": "215-615-4949"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3400 CIVIC CENTER BLVD",
            "address_2": "2 EAST PAVILLION",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191045127",
            "telephone_number": "215-615-4949"
        }
    ],
    "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": "208600000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Surgery",
            "state": "PA",
            "license": null,
            "primary": false
        },
        {
            "code": "2086S0129X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Surgery, Vascular Surgery",
            "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.