Basic Information
| Provider Information | |||||||||
| NPI: | 1629146709 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WELLSPAN FAMILY MEDICINE - STONEBRIDGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3421 CONCORD RD | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174029001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13515 WOLFE RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | NEW FREEDOM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173499346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178122501 | ||||||||
| FaxNumber: | 7174617178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 10/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FRANK | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER-CVS | ||||||||
| AuthorizedOfficialTelephone: | 7178511405 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0756543002 | 01 | PA | AMERIHEALTH 65 PA | OTHER | 596398 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 800174 | 01 | PA | JOHN HOPKINS | OTHER | 02298200 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1007721360114 | 05 | PA | MEDICAID | 1519303 | 01 | PA | GATEWAY | OTHER | 5551045 | 01 | PA | AETNA | OTHER | 82204 | 01 | PA | UNISON | OTHER | 1142414 | 01 | PA | AMERIHEALTH MERCY | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER | KX10 | 01 | MD | CAREFIRST MD BCBS | OTHER | S1E1 | 01 | PA | GEISINGER | OTHER |