Provider Demographics
NPI:1750443719
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:SPRINGDALE PEDIATRIC MEDICINE
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:717-812-3049
Practice Address - Street 1:2339 S GEORGE ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-5009
Practice Address - Country:US
Practice Address - Phone:717-812-3040
Practice Address - Fax:717-812-3049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007721360104Medicaid
PA1519307OtherGATEWAY-WINDSOR RD
PA0068573004OtherAMERIH65PA-GEORGE ST
PA20011318OtherAMERIH MERCY-RED LION
PA5643320OtherAETNA
PA82187OtherUNISON
PA1519308OtherGATEWAY-GEORGE STREET
PA0068573002OtherAMERIH65PA-RED LION
PA147455OtherHIGHMARK BLUE SHIELD
PACA3246OtherRAILROAD MEDICARE
MDKX53OtherCAREFIRST MD BCBS
PA1142418OtherAMERIH MERCY-GEORGE ST
PA800174OtherJOHN HOPKINS
PA1007721360097Medicaid
PAS1E0OtherGEISINGER
PA03058500OtherCAPITAL BLUE CROSS
PAS1E0OtherGEISINGER
PA1519308OtherGATEWAY-GEORGE STREET
PA1007721360104Medicaid