Basic Information
| Provider Information | |||||||||
| NPI: | 1972664068 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | YORK PEDIATRIC 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: | 7178468185 | ||||||||
| Practice Location | |||||||||
| Address1: | 2050 S QUEEN ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174034829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178124240 | ||||||||
| FaxNumber: | 7178485520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 12/23/2015 | ||||||||
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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 | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0068581001 | 01 | PA | AMERIH65PA-QUEEN ST | OTHER | 1007721360101 | 05 | PA | MEDICAID | 1519312 | 01 | PA | GATEWAY-CARLISLE RD | OTHER | 1142399 | 01 | PA | AMERIH MERCY-QUEEN ST | OTHER | 82152 | 01 | PA | UNISON | OTHER | S1E5 | 01 | PA | GEISINGER | OTHER | 1519311 | 01 | PA | GATEWAY-QUEEN ST | OTHER | 4509645 | 01 | PA | AETNA | OTHER | 20005265 | 01 | PA | AMERIH MERCY-CARLISLE RD | OTHER | 455070 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 800174 | 01 | PA | JOHN HOPKINS | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER | KX53 | 01 | MD | CAREFIRST MD BCBS | OTHER | 0068581003 | 01 | PA | AMERIH65PA-CARLISLE RD | OTHER | 03124100 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1007721360090 | 05 | PA | MEDICAID |