Basic Information
Provider Information | |||||||||
NPI: | 1588969307 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WELLSPAN SURGERY AND REHABILITATION HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WELLSPAN SURGERY AND REHABILITATION HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 785 5TH AVE STE 3 | ||||||||
Address2: |   | ||||||||
City: | CHAMBERSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 172014232 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172639555 | ||||||||
FaxNumber: | 7177096529 | ||||||||
Practice Location | |||||||||
Address1: | 55 MONUMENT RD. | ||||||||
Address2: | WELLSPAN SURGERY AND REHABILITATION HOSPITAL-MRU | ||||||||
City: | YORK | ||||||||
State: | PA | ||||||||
PostalCode: | 17403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7178126100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/26/2011 | ||||||||
LastUpdateDate: | 11/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUCZKOWSKI | ||||||||
AuthorizedOfficialFirstName: | LAURA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SR. VP AND CFO | ||||||||
AuthorizedOfficialTelephone: | 4104423373 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WELLSPAN SURGERY AND REHABILITATION HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X |   |   | Y |   | Hospital Units | Rehabilitation Unit |   |
ID Information
ID | Type | State | Issuer | Description | 259852 | 01 | PA | JOHNS HOPKINS HEALTHCARE | OTHER | 1606592 | 01 | PA | GATEWAY | OTHER | 102704903 | 05 | PA |   | MEDICAID |