Basic Information
Provider Information
NPI: 1093883084
EntityType: 2
ReplacementNPI:  
OrganizationName: WELLSPAN MEDICAL GROUP
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: WELLSPAN INTERNAL MEDICINE - APPLE HILL
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3421 CONCORD RD
Address2:  
City: YORK
State: PA
PostalCode: 174029001
CountryCode: US
TelephoneNumber: 7178511405
FaxNumber: 7177418016
Practice Location
Address1: 25 MONUMENT RD
Address2: SUITE 140
City: YORK
State: PA
PostalCode: 174035057
CountryCode: US
TelephoneNumber: 7177418003
FaxNumber: 7177418016
Other Information
ProviderEnumerationDate: 11/30/2006
LastUpdateDate: 09/29/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: MOON
AuthorizedOfficialFirstName: CHRISTINA
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CREDENTIALING COORDINATOR
AuthorizedOfficialTelephone: 7178511405
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MS.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363L00000X  N193200000X MULTI-SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner 
207R00000X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal Medicine 

ID Information
IDTypeStateIssuerDescription
KX5401MDCAREFIRST MD BCBSOTHER
0229410001PACAPITAL BLUE CROSSOTHER
100772136008905PA MEDICAID
114227701PAAMERIHEALTHOTHER
3009441701PAAMERIHEALTH MERCY - WMGOTHER
75614200101PAAMERIHEALTH 65 PAOTHER
80017401PAJOHN HOPKINSOTHER
S1EK01PAGEISINGEROTHER
151930501PAGATEWAYOTHER
59525201PAHIGHMARK BLUE SHIELDOTHER
566905101PAAETNAOTHER
8275001PAUNISONOTHER
CA324601PARAILROAD MEDICAREOTHER


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