Basic Information
| Provider Information | |||||||||
| NPI: | 1780839167 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | WELLSPAN ORTHOPEDICS-YORK | ||||||||
| 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: | 7178124092 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 MONUMENT RD | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174035073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178124090 | ||||||||
| FaxNumber: | 7178124092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2008 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILKINSON | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7178511401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0801X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207X00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1578892 | 01 | PA | GATEWAY | OTHER | 100772136 | 05 | PA | MEDICAID | 9729320 | 01 | PA | AETNA | OTHER | 2084822 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 401065515 | 05 | MD | MEDICAID | 42737 | 01 | PA | GEISINGER HEALTH PLAN | OTHER | 50083200 | 01 | PA | CAPITAL BLUE CROSS-WMG | OTHER | DZV3 | 01 | MD | CAREFIRST MD BCBS | OTHER |