Basic Information
| Provider Information | |||||||||
| NPI: | 1407916018 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | WELLSPAN RHEUMATOLOGY | ||||||||
| 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: | 7178516243 | ||||||||
| Practice Location | |||||||||
| Address1: | 292 SAINT CHARLES WAY | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174024648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178516236 | ||||||||
| FaxNumber: | 7178516243 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| 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 | 207RR0500X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 1007721360236 | 05 | PA | MEDICAID | 1519844 | 01 | PA | GATEWAY | OTHER | 7235852 | 01 | PA | AETNA | OTHER | KY95 | 01 | MD | CAREFIRST BCBS | OTHER | 124903 | 01 | PA | UNISON | OTHER | 800174 | 01 | PA | JOHN HOPKINS | OTHER | 0756540000 | 01 | PA | AMERIHEALTH 65PA | OTHER | 1007721360081 | 05 | PA | MEDICAID | 50065210 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1142800 | 01 | PA | AMERIHEALTH MERCY | OTHER | 335T | 01 | PA | GEISINGER | OTHER | 596384 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER |