Provider Demographics
NPI:1861666174
Name:JEFFERSON UNIVERSITY PHYSICIAN
Entity type:Organization
Organization Name:JEFFERSON UNIVERSITY PHYSICIAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNKEYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-955-2562
Mailing Address - Street 1:833 CHESTNUT ST
Mailing Address - Street 2:SUITE 630
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:833 CHESTNUT ST
Practice Address - Street 2:SUITE 630
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4414
Practice Address - Country:US
Practice Address - Phone:215-955-0800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7512007Medicaid
PA1153258OtherKEYSTONE MERCY
NJ7531303Medicaid
NJ7535805Medicaid
PA1153629OtherKEYSTONE MERCY
PA2678933000OtherINDEPENDENCE BLUE CROSS
NJ7531401Medicaid
NJ8455708Medicaid
NJ7551703Medicaid
PA1153628OtherKEYSTONE MERCY
PA1153665OtherKEYSTONE MERCY
PA1156151OtherKEYSTONE MERCY
PA1153651OtherKEYSTONE MERCY
PA1821657OtherHIGHMARK BLUE SHIELD
PA507462OtherAETNA
NJ7550405Medicaid
NJ7585403Medicaid
PA1062654OtherKEYSTONE MERCY
PA1153656OtherKEYSTONE MERCY