Basic Information
| Provider Information | |||||||||
| NPI: | 1801954276 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. CHARLES INTERNAL MEDICINE | ||||||||
| 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: | 7178516577 | ||||||||
| Practice Location | |||||||||
| Address1: | 296 ST. CHARLES WAY | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174024648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178516567 | ||||||||
| FaxNumber: | 7178516577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 08/11/2010 | ||||||||
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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 | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0021280001 | 01 | PA | AMERIHEALTH 65 PA | OTHER | 02293500 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1007721360132 | 05 | PA | MEDICAID | 84533 | 01 | PA | UNISON | OTHER | 1142430 | 01 | PA | AMERIHEALTH MERCY | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER | 369120 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 800174 | 01 | PA | JOHN HOPKINS | OTHER | KX54 | 01 | MD | CAREFIRST MD BCBS | OTHER | S1EZ | 01 | PA | GEISINGER | OTHER | 1519314 | 01 | PA | GATEWAY | OTHER | 5894771 | 01 | PA | AETNA | OTHER |