Basic Information
| Provider Information | |||||||||
| NPI: | 1457439531 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | WELLSPAN MATERNAL FETAL MEDICINE | ||||||||
| 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: | 7178513127 | ||||||||
| Practice Location | |||||||||
| Address1: | 35 MONUMENT RD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174035074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178512722 | ||||||||
| FaxNumber: | 7178513127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 01/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | VEST | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
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| 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 | 207VM0101X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1007721360263 | 05 | PA | MEDICAID | 1520915 | 01 | PA | GATEWAY | OTHER | KX03 | 01 | PA | CAREFIRST MD BCBS | OTHER | 5673117 | 01 | PA | AETNA | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER | 02308800 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 341T | 01 | PA | GEISINGER HP | OTHER | 640230 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 0510126000 | 01 | PA | AMERIHEALTH 65PA | OTHER | 1007721360128 | 05 | PA | MEDICAID | 20010208 | 01 | PA | AMERIHEALTH MERCY | OTHER | 401065506 | 05 | MD | MEDICAID | 401065508 | 05 | MD | MEDICAID | 82209 | 01 | PA | UNISON | OTHER | 401065507 | 05 | MD | MEDICAID | 1007721360242 | 05 | PA | MEDICAID | 800174 | 01 | PA | JOHN HOPKINS HP | OTHER |