Basic Information
| Provider Information | |||||||||
| NPI: | 1386194850 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | WELLSPAN INTERNAL MEDICINE - EPHRATA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3421 CONCORD RD | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174029001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | 7178516969 | ||||||||
| Practice Location | |||||||||
| Address1: | 446 N READING RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | EPHRATA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175229802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177336546 | ||||||||
| FaxNumber: | 7177336010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2016 | ||||||||
| LastUpdateDate: | 10/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | MOON | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SUPERVISOR-VERIFICATION SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7178511405 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.