Basic Information
| Provider Information | |||||||||
| NPI: | 1669644183 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | GETTYSBURG SURGICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1803 MOUNT ROSE AVE | ||||||||
| Address2: | SUITE B3 | ||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174033026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | 7173393108 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 S WASHINGTON ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | GETTYSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173252500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7173393110 | ||||||||
| FaxNumber: | 7173393108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2008 | ||||||||
| LastUpdateDate: | 11/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | WILKINSON | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7178511405 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 208600000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 50075811 | 01 | PA | CAPITAL BLUE CROSS WMG | OTHER | 100772136 | 05 | PA | MEDICAID | 232730 | 01 | PA | UNISON WMG | OTHER | 1538201 | 01 | PA | GATEWAY-WMG | OTHER | 2016471 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 20072208 | 01 | PA | AMERIHEALTH MERCY-WMG | OTHER | 655T | 01 | PA | GEISINGER | OTHER | KC94 | 01 | PA | CAREFIRST MD BCBS | OTHER |