Basic Information
| Provider Information | |||||||||
| NPI: | 1215994934 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BROCKIE INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1803 MOUNT ROSE AVE | ||||||||
| Address2: | SUITE B3 | ||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174033051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | 7178436682 | ||||||||
| Practice Location | |||||||||
| Address1: | 924 COLONIAL AVE STE B | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174033450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178458623 | ||||||||
| FaxNumber: | 7178436682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 08/10/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILKINSON | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7178511405 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 800174 | 01 | PA | JOHN HOPKINS | OTHER | 0068498001 | 01 | PA | AMERI 65PA COLONIAL | OTHER | 03005700 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1519824 | 01 | PA | GATEWAY | OTHER | 20010095 | 01 | PA | AMERIHEALTH GEORGE ST | OTHER | 1007721360092 | 05 | PA | MEDICAID | 354T | 01 | PA | GEISINGER SP | OTHER | S1EM | 01 | PA | GEISINGER PCP | OTHER | 0068498000 | 01 | PA | AMERI 65PA GEORGE ST | OTHER | 5126007 | 01 | PA | AETNA | OTHER | 059784 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 100721360243 | 05 | PA | MEDICAID | 82194 | 01 | PA | UNISON COLONIAL AVE | OTHER | DJ3Q | 01 | MD | CAREFIRST MD BCBS | OTHER | 1142285 | 01 | PA | AMERIHEALTH COLONIAL AVE | OTHER | 82201 | 01 | PA | UNISON GEORGE ST | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER |