Provider Demographics
NPI:1346488764
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN SURGICAL ONCOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
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:17403-3026
Mailing Address - Country:US
Mailing Address - Phone:717-851-1405
Mailing Address - Fax:717-741-8217
Practice Address - Street 1:25 MONUMENT RD
Practice Address - Street 2:SUITE 220
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-5049
Practice Address - Country:US
Practice Address - Phone:717-812-7676
Practice Address - Fax:717-812-5176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100772136Medicaid
PA1578610OtherGATEWAY-WMG
PA9095312OtherAETNA
PA50083176OtherCAPITAL BLUE CROSS-WMG
PA2086650OtherHIGHMARK BLUE SHIELD
PA20082423OtherAMERIHEALTH MERCY-WMG
PA261028OtherUNISON-WMG
MDF0WKWEOtherCAREFIRST MD BCBS
PA261028OtherUNISON-WMG