Basic Information
| Provider Information | |||||||||
| NPI: | 1417133448 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WELLSPAN URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3421 CONCORD RD | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174029001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 435 S KINZER AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HOLLAND | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175578706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7173512419 | ||||||||
| FaxNumber: | 7173512422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 09/25/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLMES | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7177386845 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CFO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.