Basic Information
| Provider Information | |||||||||
| NPI: | 1588249668 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3421 CONCORD RD | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174029001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | 7178516969 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 WESTERN MARYLAND PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217405471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017979240 | ||||||||
| FaxNumber: | 3017979240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2021 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | FRANK | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7178516832 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.