Basic Information
| Provider Information | |||||||||
| NPI: | 1811065626 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | WELLSPAN FAMILY MEDICINE - BANNISTER ST | ||||||||
| 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: | 7178122010 | ||||||||
| Practice Location | |||||||||
| Address1: | 1575 BANNISTER ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174044946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178122000 | ||||||||
| FaxNumber: | 7178122010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| 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 | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1007721360094 | 05 | PA | MEDICAID | 1519300 | 01 | PA | GATEWAY | OTHER | KX10 | 01 | MD | CAREFIRST MD BCBS | OTHER | 03006400 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 107496 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 4474210 | 01 | PA | AETNA | OTHER | 800174 | 01 | PA | JOHN HOPKINS | OTHER | 82186 | 01 | PA | UNISON | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER | S1E6 | 01 | PA | GEISINGER | OTHER | 0068841001 | 01 | PA | AMERIHEALTH 65 PA | OTHER | 1142406 | 01 | PA | AMERIHEALTH MERCY | OTHER |