Basic Information
| Provider Information | |||||||||
| NPI: | 1770669897 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | WELLSPAN GERIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3421 CONCORD RD | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174029001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | 7178516162 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 PINE GROVE COMMONS | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174035151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178515736 | ||||||||
| FaxNumber: | 7178516162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 11/06/2014 | ||||||||
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| AuthorizedOfficialLastName: | WILKINSON | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| 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 | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207QA0505X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 102961 | 01 | PA | UNISON SPEC | OTHER | 1520440 | 01 | PA | GATEWAY | OTHER | 7350452 | 01 | PA | AETNA | OTHER | 800174 | 01 | PA | JOHN HOPKINS HP | OTHER | 122902 | 01 | PA | UNISON PCP | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER | KX54 | 01 | CAREFIRST MD BC/BS | OTHER | S1EN | 01 | PA | GEISINGER PCP | OTHER | 191576 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 03001500 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1007721360239 | 05 | PA | MEDICAID | 1142339 | 01 | PA | AMERIHEALTH MERCY | OTHER | 272S | 01 | PA | GEISINGER SP | OTHER |