Basic Information
| Provider Information | |||||||||
| NPI: | 1831251792 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | WELLSPAN NEUROLOGY | ||||||||
| 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: | 7178515507 | ||||||||
| Practice Location | |||||||||
| Address1: | 228 SAINT CHARLES WAY | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174024644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178515503 | ||||||||
| FaxNumber: | 7178515507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 05/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | WILKINSON | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| 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 | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 2084N0600X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0402X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084N0400X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1523767 | 01 | PA | GATEWAY | OTHER | 032240400 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1007721360139 | 05 | PA | MEDICAID | 1341685 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 1007721360296 | 05 | PA | MEDICAID | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER | 20013275 | 01 | PA | AMERIHEALTH MERCY | OTHER | 7465868 | 01 | PA | AETNA | OTHER | 800174 | 01 | PA | JOHN HOPKINS | OTHER | 1007721360110 | 05 | PA | MEDICAID | 337T | 01 | PA | GEISINGER | OTHER | KBE4 | 01 | MD | CAREFIRST BCBS | OTHER |