Provider Demographics
NPI:1598862716
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN READYCARE
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:717-851-1569
Practice Address - Street 1:1101 EDGAR ST
Practice Address - Street 2:SUITE E
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-2862
Practice Address - Country:US
Practice Address - Phone:717-851-1566
Practice Address - Fax:717-851-1569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50062674OtherCAPITAL BLUE CROSS
PA20054647OtherAMERIHEALTH MERCY
PA1874423OtherHIGHMARK WELLSPAN MG
PA1007721360261Medicaid
PA417TOtherGEISINGER
PA7594870OtherAETNA
PACA3246OtherRAILROAD MEDICARE
MD19WWOtherCAREFIRST BCBS
PA800174OtherJOHN HOPKINS WELLSPAN MG
PA1874423OtherHIGHMARK WELLSPAN MG
PA7594870OtherAETNA
PA50062674OtherCAPITAL BLUE CROSS