Basic Information
| Provider Information | |||||||||
| NPI: | 1114088408 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1803 MOUNT ROSE AVE | ||||||||
| Address2: | SUITE B3 | ||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174033051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | 7178516301 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 MONUMENT RD STE 105 | ||||||||
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| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174035049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178517575 | ||||||||
| FaxNumber: | 7178125154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 01/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | VEST | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7178511405 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QB0002X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Bariatric Medicine | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207RB0002X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Bariatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 152996 | 01 | PA | UNISON MUZZIO | OTHER | 20036194 | 01 | PA | AMERIHEALTH MERCY | OTHER | 1946212 | 01 | PA | HIGHMARK | OTHER | 800174 | 01 | PA | JOHN HOPKINS | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER | 169903 | 01 | PA | UNISON TURKEWITZ | OTHER | 356T | 01 | PA | GEISINGER | OTHER | 756142008 | 01 | PA | AMERIHEALTH 65 PA | OTHER | 1007721360252 | 05 | PA | MEDICAID | KX54 | 01 | MD | CAREFIRST BCBS | OTHER | 50041721 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 7254857 | 01 | PA | AETNA | OTHER |