Basic Information
| Provider Information | |||||||||
| NPI: | 1760568885 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | GETTYSBURG HOSPITALISTS | ||||||||
| 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: | 7173392011 | ||||||||
| Practice Location | |||||||||
| Address1: | 147 GETTYS ST | ||||||||
| Address2: | |||||||||
| City: | GETTYSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173252534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7173392025 | ||||||||
| FaxNumber: | 7173392011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 08/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | WILKINSON | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| 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 | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 20048461 | 01 | PA | AMERIHEALTH MERCY | OTHER | 2631128001 | 01 | PA | AMERIHEALTH 65PA | OTHER | 7726910 | 01 | PA | AETNA | OTHER | 1007721360249 | 05 | PA | MEDICAID | 1551482 | 01 | PA | GATEWAY | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER | 175372 | 01 | PA | UNISON | OTHER | 401065509 | 01 | MD | MD MEDICAL ASSISTANCE | OTHER | 1789770 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 50055993 | 01 | PA | CAPITAL BLUE CROSS | OTHER | KX54 | 01 | PA | CAREFIRST MD BC/BS | OTHER | 271J | 01 | PA | GEISINGER | OTHER |