Basic Information
| Provider Information | |||||||||
| NPI: | 1558468777 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | WELLSPAN SURGICAL ASSOCIATES | ||||||||
| 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: | 7178511999 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 S QUEEN ST | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174034630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178516110 | ||||||||
| FaxNumber: | 7178482074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 12/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | WILKINSON | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COODINATOR | ||||||||
| 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 | 2086S0102X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0129X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02321100 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 118975 | 01 | PA | UNISON WELLSPAN MG | OTHER | 331T | 01 | PA | GEISINGER | OTHER | 0667146000 | 01 | PA | AMERIHEALTH 65PA | OTHER | 800174 | 01 | PA | JOHN HOPKINS WELLSPAN MG | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER | 7931883 | 01 | PA | AETNA | OTHER | D83N | 01 | MD | CAREFIRST MD BCBS-WMG | OTHER | 1007721360135 | 05 | PA | MEDICAID | 401065510 | 05 | MD | MEDICAID | 117038 | 01 | PA | HIGHMARK WELLSPAN MG | OTHER | 20010753 | 01 | PA | AMERIHEALTH MERCY | OTHER |