Provider Demographics
NPI:1194819193
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN NEUROSURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:F
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-851-1405
Mailing Address - Street 1:1803 MOUNT ROSE AVE
Mailing Address - Street 2:SUITE B3
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17403-3051
Mailing Address - Country:US
Mailing Address - Phone:717-851-1405
Mailing Address - Fax:717-741-3598
Practice Address - Street 1:228 SAINT CHARLES WAY
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-4644
Practice Address - Country:US
Practice Address - Phone:717-747-9911
Practice Address - Fax:717-741-3598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7176837OtherGATEWAY
PA7191896OtherAETNA
PA2753686000OtherAMERIHEALTH 65PA
PA1007721360255Medicaid
PA20054026OtherAMERIHEALTH MERCY WMG
MD401065512Medicaid
PA50060981OtherCAPITAL BLUE CROSS
PA800174OtherJOHN HOPKINS
PA1886854OtherHIGHMARK
MD20FQOtherCAREFIRST BC/BS
PA1007721360256Medicaid
PACA3246OtherRAILROAD MEDICARE
PA418TOtherGEISINGER
PA800174OtherJOHN HOPKINS
PA=========028OtherTRICARE
PA=========028OtherTRICARE