Provider Demographics
NPI:1407916018
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN RHEUMATOLOGY
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:717-851-6243
Practice Address - Street 1:292 SAINT CHARLES WAY
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-4648
Practice Address - Country:US
Practice Address - Phone:717-851-6236
Practice Address - Fax:717-851-6243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007721360236Medicaid
PA1519844OtherGATEWAY
PA7235852OtherAETNA
MDKY95OtherCAREFIRST BCBS
PA124903OtherUNISON
PA800174OtherJOHN HOPKINS
PA0756540000OtherAMERIHEALTH 65PA
PA1007721360081Medicaid
PA50065210OtherCAPITAL BLUE CROSS
PA1142800OtherAMERIHEALTH MERCY
PA335TOtherGEISINGER
PA596384OtherHIGHMARK BLUE SHIELD
PACA3246OtherRAILROAD MEDICARE
PA335TOtherGEISINGER
PACA3246OtherRAILROAD MEDICARE
PA=========091OtherTRICARE WASHINGTON ST