Basic Information
| Provider Information | |||||||||
| NPI: | 1265054308 | ||||||||
| 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: | 35 MONUMENT RD STE 204 | ||||||||
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| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174035074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178512443 | ||||||||
| FaxNumber: | 7178516129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2020 | ||||||||
| LastUpdateDate: | 05/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | DIAZ | ||||||||
| AuthorizedOfficialFirstName: | JULIANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR. CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7178517134 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
No ID Information.