Basic Information
| Provider Information | |||||||||
| NPI: | 1124104245 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | WELLSPAN PEDIATRIC HOSPITALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 7178513382 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 S GEORGE ST | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174033676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178513884 | ||||||||
| FaxNumber: | 7178513382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 01/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | VEST | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7178511405 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0204X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 208000000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7783839 | 01 | PA | AETNA | OTHER | HIGHMARK | 01 | PA | 1955304 | OTHER | 03005900 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 174862 | 01 | PA | UNISON HP | OTHER | 1548228 | 01 | PA | GATEWAY | OTHER | 800174 | 01 | PA | JOHN HOPKINS HP | OTHER | 68581007 | 01 | PA | AMERIHEALTH 65 PA | OTHER | KX53 | 01 | PA | CAREFIRST MD BC/BS | OTHER | 20016312 | 01 | PA | AMERIHEALTH MERCY | OTHER | 1007721360260 | 05 | PA | MEDICAID | 339T | 01 | PA | GEISINGER | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER |