Provider Demographics
NPI:1558468777
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COODINATOR
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:717-851-1999
Practice Address - Street 1:1601 S QUEEN ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-4630
Practice Address - Country:US
Practice Address - Phone:717-851-6110
Practice Address - Fax:717-848-2074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Single Specialty
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Single Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02321100OtherCAPITAL BLUE CROSS
PA118975OtherUNISON WELLSPAN MG
PA331TOtherGEISINGER
PA0667146000OtherAMERIHEALTH 65PA
PA800174OtherJOHN HOPKINS WELLSPAN MG
PACA3246OtherRAILROAD MEDICARE
PA7931883OtherAETNA
MDD83NOtherCAREFIRST MD BCBS-WMG
PA1007721360135Medicaid
MD401065510Medicaid
PA117038OtherHIGHMARK WELLSPAN MG
PA20010753OtherAMERIHEALTH MERCY
PA=========093OtherTRICARE WELLSPAN MG
PA=========093OtherTRICARE WELLSPAN MG