Basic Information
| Provider Information | |||||||||
| NPI: | 1659449031 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WELLSPAN FAMILY MEDICINE - PLYMOUTH RD | ||||||||
| 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: | 7178511810 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 PLYMOUTH RD | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174023864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511800 | ||||||||
| FaxNumber: | 7178511810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 01/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | VEST | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7178511405 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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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 | 0202925002 | 01 | PA | AMERIHEALTH 65 PA | OTHER | 5203300 | 01 | PA | AETNA | OTHER | 1007721360099 | 05 | PA | MEDICAID | 1142354 | 01 | PA | AMERIHEALTH MERCY | OTHER | S1ES | 01 | PA | GEISINGER | OTHER | KX10 | 01 | MD | CAREFIRST MD BCBS | OTHER | 1519295 | 01 | PA | GATEWAY | OTHER | 800174 | 01 | PA | JOHN HOPKINS | OTHER | 02293800 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 501286 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 82193 | 01 | PA | UNISON | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER |