Provider Demographics
NPI:1073756672
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN PULMONARY AND SLEEP MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP AND CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCZKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-259-0783
Mailing Address - Street 1:601 MEMORY LN STE B3
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-2231
Mailing Address - Country:US
Mailing Address - Phone:717-851-1405
Mailing Address - Fax:717-741-3043
Practice Address - Street 1:2350 FREEDOM WAY
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-8200
Practice Address - Country:US
Practice Address - Phone:717-851-2465
Practice Address - Fax:717-741-3043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-13
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1581228OtherGATEWAY-WMG
PA100772136Medicaid
PA2108539OtherHIGHMARK BLUE SHIELD
PA9930316OtherAETNA
PA20087275OtherAMERIHEALTH MERCY-WMG
PA271360OtherUNISON-WMG
PA20087275OtherAMERIHEALTH MERCY-WMG