Basic Information
| Provider Information | |||||||||
| NPI: | 1750443719 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SPRINGDALE PEDIATRIC MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1803 MOUNT ROSE AVE | ||||||||
| Address2: | SUITE B3 | ||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174033051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | 7178123049 | ||||||||
| Practice Location | |||||||||
| Address1: | 2339 S GEORGE ST | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174035009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178123040 | ||||||||
| FaxNumber: | 7178123049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 08/11/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILKINSON | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7178511405 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1007721360104 | 05 | PA | MEDICAID | 1519307 | 01 | PA | GATEWAY-WINDSOR RD | OTHER | 0068573004 | 01 | PA | AMERIH65PA-GEORGE ST | OTHER | 20011318 | 01 | PA | AMERIH MERCY-RED LION | OTHER | 5643320 | 01 | PA | AETNA | OTHER | 82187 | 01 | PA | UNISON | OTHER | 1519308 | 01 | PA | GATEWAY-GEORGE STREET | OTHER | 0068573002 | 01 | PA | AMERIH65PA-RED LION | OTHER | 147455 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER | KX53 | 01 | MD | CAREFIRST MD BCBS | OTHER | 1142418 | 01 | PA | AMERIH MERCY-GEORGE ST | OTHER | 800174 | 01 | PA | JOHN HOPKINS | OTHER | 1007721360097 | 05 | PA | MEDICAID | S1E0 | 01 | PA | GEISINGER | OTHER | 03058500 | 01 | PA | CAPITAL BLUE CROSS | OTHER |