Basic Information
| Provider Information | |||||||||
| NPI: | 1194819193 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | WELLSPAN NEUROSURGERY | ||||||||
| 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: | 7177413598 | ||||||||
| Practice Location | |||||||||
| Address1: | 228 SAINT CHARLES WAY | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174024644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177479911 | ||||||||
| FaxNumber: | 7177413598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | WILKINSON | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| 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 | 207T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7176837 | 01 | PA | GATEWAY | OTHER | 7191896 | 01 | PA | AETNA | OTHER | 2753686000 | 01 | PA | AMERIHEALTH 65PA | OTHER | 1007721360255 | 05 | PA | MEDICAID | 20054026 | 01 | PA | AMERIHEALTH MERCY WMG | OTHER | 401065512 | 05 | MD | MEDICAID | 50060981 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 800174 | 01 | PA | JOHN HOPKINS | OTHER | 1886854 | 01 | PA | HIGHMARK | OTHER | 20FQ | 01 | MD | CAREFIRST BC/BS | OTHER | 1007721360256 | 05 | PA | MEDICAID | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER | 418T | 01 | PA | GEISINGER | OTHER |