Provider Demographics
NPI:1780839167
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN ORTHOPEDICS-YORK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
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:717-851-1401
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:717-812-4092
Practice Address - Street 1:25 MONUMENT RD
Practice Address - Street 2:SUITE 290
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-5073
Practice Address - Country:US
Practice Address - Phone:717-812-4090
Practice Address - Fax:717-812-4092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-26
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic TraumaGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1578892OtherGATEWAY
PA100772136Medicaid
PA9729320OtherAETNA
PA2084822OtherHIGHMARK BLUE SHIELD
MD401065515Medicaid
PA42737OtherGEISINGER HEALTH PLAN
PA50083200OtherCAPITAL BLUE CROSS-WMG
MDDZV3OtherCAREFIRST MD BCBS
PA1578892OtherGATEWAY
PA117038FLTMedicare PIN