NPIMap

Organization Active NPI

University of Penn-Medical Group

  • Urology Physician
  • Philadelphia, PA
National Provider Identifier
1801284823
Registry record updated Nov 20, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Urology PhysicianTaxonomy code 208800000X
Legal business name
UNIVERSITY OF PENN-MEDICAL GROUP
Practice address
3400 Civic Center Blvd
West Pavilion, 3Rd Floor
Philadelphia, PA 19104-5127
Phone
(215) 662-2891
NPI assigned
Dec 29, 2014
Last updated
Nov 20, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 20, 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
Urology Physician 208800000X PA Primary

Addresses

Primary practice location

3400 Civic Center Blvd
West Pavilion, 3Rd Floor
Philadelphia, PA 19104-5127

Mailing address

3400 Civic Center Blvd
West Pavilion, 3Rd Floor
Philadelphia, PA 19104-5127
Phone (215) 662-2891

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

Locations

3400 Spruce St
#1000
Philadelphia, PA 19104
Phone (215) 615-5234

145 King of Prussia Rd
Ste 203
St Davids, PA 19087
Phone (215) 662-8664

Practitioners & affiliated clinicians

Practitioners 65

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 65

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": "1605830400000",
    "number": "1801284823",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3400 CIVIC CENTER BLVD",
            "address_2": "WEST PAVILION, 3RD FLOOR",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191045127",
            "telephone_number": "215-662-2891"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3400 CIVIC CENTER BLVD",
            "address_2": "WEST PAVILION, 3RD FLOOR",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191045127",
            "telephone_number": "215-662-2891"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "UNIVERSITY OF PENN-MEDICAL GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-12-29",
        "last_updated": "2020-11-20",
        "certification_date": "2020-11-20",
        "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": "208800000X",
            "taxonomy_group": "",
            "desc": "Urology",
            "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 20, 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.