Basic Information
| Provider Information | |||||||||
| NPI: | 1346488764 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | WELLSPAN SURGICAL ONCOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1803 MOUNT ROSE AVE | ||||||||
| Address2: | SUITE B3 | ||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174033026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | 7177418217 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 MONUMENT RD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174035049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178127676 | ||||||||
| FaxNumber: | 7178125176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2009 | ||||||||
| LastUpdateDate: | 12/31/2015 | ||||||||
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| AuthorizedOfficialLastName: | WILKINSON | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7178511405 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 100772136 | 05 | PA | MEDICAID | 1578610 | 01 | PA | GATEWAY-WMG | OTHER | 9095312 | 01 | PA | AETNA | OTHER | 50083176 | 01 | PA | CAPITAL BLUE CROSS-WMG | OTHER | 2086650 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 20082423 | 01 | PA | AMERIHEALTH MERCY-WMG | OTHER | 261028 | 01 | PA | UNISON-WMG | OTHER | F0WKWE | 01 | MD | CAREFIRST MD BCBS | OTHER |