Basic Information
| Provider Information | |||||||||
| NPI: | 1801982426 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | WELLSPAN CENTER FOR MIND/BODY HEALTH | ||||||||
| 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: | 7178515957 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 PINE GROVE COMMONS | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174035151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178515590 | ||||||||
| FaxNumber: | 7178515957 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 01/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | VEST | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7178511405 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 672515 | 01 | PA | HIGHMARK | OTHER | KX54 | 01 | MD | CAREFIRST | OTHER | 0389907002 | 01 | PA | AMERIHEALTH 65PA | OTHER | 357T | 01 | PA | GEISINGER | OTHER | 1007721360238 | 05 | PA | MEDICAID | 800174 | 01 | PA | JOHN HOPKINS | OTHER | 20016267 | 01 | PA | AMERIHEALTH MERCY | OTHER | 03256000 | 01 | PA | CAPITAL BLUE CROSS | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER |