Basic Information
| Provider Information | |||||||||
| NPI: | 1124637608 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3421 CONCORD RD | ||||||||
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| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174029001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1101 EDGAR ST STE D | ||||||||
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| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174032862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178512924 | ||||||||
| FaxNumber: | 7178513559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2020 | ||||||||
| LastUpdateDate: | 07/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | DIAZ | ||||||||
| AuthorizedOfficialFirstName: | JULIANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR CRED COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7178517134 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.