Basic Information
| Provider Information | |||||||||
| NPI: | 1790853695 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WELLSPAN FAMILY MEDICINE - FAIRFIELD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3421 CONCORD RD | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174029001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | 7172550950 | ||||||||
| Practice Location | |||||||||
| Address1: | 4910A FAIRFIELD RD STE A | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173209201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7173393175 | ||||||||
| FaxNumber: | 7172550950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 04/06/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FRANK | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CVO-MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7178511405 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1007721360126 | 05 | PA | MEDICAID | 20013074 | 01 | PA | AMERIHEALTH MERCY | OTHER | 401065503 | 01 | MD | MARYLAND MEDICAID | OTHER | 7579833 | 01 | PA | AETNA | OTHER | S1ET | 01 | PA | GEISINGER | OTHER | 1382350 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 1527201 | 01 | PA | GATEWAY | OTHER | 2073722002 | 01 | PA | AMERIHEALTH 65 PA | OTHER | 800174 | 01 | PA | JOHN HOPKINS | OTHER | 130408 | 01 | PA | UNISON | OTHER | 462M | 01 | MD | MARYLAND MEDICARE | OTHER | CA3246 | 01 | PA | RAILROAD | OTHER | 03181900 | 01 | PA | CAPITAL BLUE CROSS | OTHER |