Basic Information
| Provider Information | |||||||||
| NPI: | 1669770004 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | WELLSPAN GASTROENTEROLOGY | ||||||||
| 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: | 7177419633 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 FREEDOM WAY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174028200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178125120 | ||||||||
| FaxNumber: | 7177413075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2011 | ||||||||
| LastUpdateDate: | 12/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | WILKINSON | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7178125120 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 50099585 | 01 | PA | CAPITAL BLUE CROSS-WMG | OTHER | 2598649 | 01 | PA | HIGHMARK BLUE SHIELD-WMG | OTHER | C8J5 | 01 | MD | CAREFIRST MD BCBS-WMG | OTHER | 1007721360299 | 05 | PA | MEDICAID | 1593952 | 01 | PA | GATEWAY-WMG | OTHER | 9203695 | 01 | PA | AETNA-WMG | OTHER | 30088992 | 01 | PA | AMERIHEALTH MERCY-WMG | OTHER |