Basic Information
| Provider Information | |||||||||
| NPI: | 1649348525 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WELLSPAN FAMILY MEDICINE - EAST BERLIN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 105 4TH ST # 727 | ||||||||
| Address2: | |||||||||
| City: | EAST BERLIN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173169638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178124900 | ||||||||
| FaxNumber: | 7172550951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FRANK | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER/CVS | ||||||||
| AuthorizedOfficialTelephone: | 7178516832 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 82212 | 01 | PA | UNISON | OTHER | 1519296 | 01 | PA | GATEWAY | OTHER | 597344 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | KX10 | 01 | MD | CAREFIRST MD BCBS | OTHER | 0756905001 | 01 | PA | AMERIHEALTH 65 PA | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER | S1ER | 01 | PA | GEISINGER | OTHER | 02293300 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1007721360095 | 05 | PA | MEDICAID | 1142342 | 01 | PA | AMERIHEALTH MERCY | OTHER | 5388041 | 01 | PA | AETNA | OTHER | 800174 | 01 | PA | JOHN HOPKINS | OTHER |