Basic Information
Provider Information | |||||||||
NPI: | 1073756672 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WELLSPAN PULMONARY AND SLEEP MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1803 MT ROSE AVE | ||||||||
Address2: | SUITE B3 | ||||||||
City: | YORK | ||||||||
State: | PA | ||||||||
PostalCode: | 174033051 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7178511405 | ||||||||
FaxNumber: | 7177413043 | ||||||||
Practice Location | |||||||||
Address1: | 227 GRANITE RUN DR STE 110 | ||||||||
Address2: |   | ||||||||
City: | LANCASTER | ||||||||
State: | PA | ||||||||
PostalCode: | 176016813 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7178512465 | ||||||||
FaxNumber: | 7177413043 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/13/2009 | ||||||||
LastUpdateDate: | 11/15/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VEST | ||||||||
AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 7178511405 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RS0012X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207R00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1581228 | 01 | PA | GATEWAY-WMG | OTHER | 2108539 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 9930316 | 01 | PA | AETNA | OTHER | 100772136 | 05 | PA |   | MEDICAID | 20087275 | 01 | PA | AMERIHEALTH MERCY-WMG | OTHER | 271360 | 01 | PA | UNISON-WMG | OTHER |