Provider Demographics
NPI:1407019466
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN PHYSIATRY
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:717-851-5507
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:717-812-2212
Practice Address - Fax:717-851-5507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA20080294OtherAMERIHEALTH MERCY-WMG
PA249013OtherUNISON-WMG
PA100772136Medicaid
PA9265277OtherAETNA
PA2063424OtherHIGHMARK BLUE SHIELD
PA363YOtherGEISINGER HEALTH PLAN
MDFGB5OtherCAREFIRST MD BCBS
PA20080294OtherAMERIHEALTH MERCY-WMG