Provider Demographics
NPI:1538210380
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:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:PENDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:215-898-4417
Mailing Address - Street 1:4101 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4510
Mailing Address - Country:US
Mailing Address - Phone:215-573-7200
Mailing Address - Fax:215-573-4442
Practice Address - Street 1:4101 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4510
Practice Address - Country:US
Practice Address - Phone:215-573-7200
Practice Address - Fax:215-573-4442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH3908Medicare ID - Type UnspecifiedPACE PROGRAM