Provider Demographics
NPI:1669644183
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:GETTYSBURG SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
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:717-339-3108
Practice Address - Street 1:450 S WASHINGTON ST
Practice Address - Street 2:SUITE C
Practice Address - City:GETTYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17325-2500
Practice Address - Country:US
Practice Address - Phone:717-339-3110
Practice Address - Fax:717-339-3108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2014-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50075811OtherCAPITAL BLUE CROSS WMG
PA100772136Medicaid
PA232730OtherUNISON WMG
PA1538201OtherGATEWAY-WMG
PA2016471OtherHIGHMARK BLUE SHIELD
PA20072208OtherAMERIHEALTH MERCY-WMG
PA655TOtherGEISINGER
PAKC94OtherCAREFIRST MD BCBS
PA232730OtherUNISON WMG
PA1538201OtherGATEWAY-WMG