Basic Information
| Provider Information | |||||||||
| NPI: | 1407019466 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WELLSPAN PHYSIATRY | ||||||||
| 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: | 7178515507 | ||||||||
| Practice Location | |||||||||
| Address1: | 228 SAINT CHARLES WAY | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174024644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178122212 | ||||||||
| FaxNumber: | 7178515507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2008 | ||||||||
| LastUpdateDate: | 05/14/2013 | ||||||||
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| AuthorizedOfficialLastName: | WILKINSON | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| 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 | 208100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 20080294 | 01 | PA | AMERIHEALTH MERCY-WMG | OTHER | 249013 | 01 | PA | UNISON-WMG | OTHER | 100772136 | 05 | PA | MEDICAID | 9265277 | 01 | PA | AETNA | OTHER | 2063424 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 363Y | 01 | PA | GEISINGER HEALTH PLAN | OTHER | FGB5 | 01 | MD | CAREFIRST MD BCBS | OTHER |