Basic Information
| Provider Information | |||||||||
| NPI: | 1265591481 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PINE GROVE ADULT MEDICINE | ||||||||
| 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: | 7178122163 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 PINE GROVE COMMONS | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174035176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178122143 | ||||||||
| FaxNumber: | 7178122163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 08/11/2010 | ||||||||
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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 | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 800174 | 01 | PA | JOHN HOPKINS | OTHER | 1007721360258 | 05 | PA | MEDICAID | KX54 | 01 | MD | CAREFIRST MD BCBS | OTHER | 50023472 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1471291 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 1531858 | 01 | PA | GATEWAY | OTHER | 20022918 | 01 | PA | AMERIHEALTH MERCY | OTHER | 2155344001 | 01 | PA | AMERIHEALTH 65 PA | OTHER | 7689843 | 01 | PA | AETNA | OTHER | S1EY | 01 | PA | GEISINGER | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER |