Provider Demographics
NPI:1790061844
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN CERTIFIED NURSE-MIDWIVES
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:717-841-1405
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:717-334-0045
Mailing Address - Fax:717-334-2226
Practice Address - Street 1:455 S WASHINGTON ST
Practice Address - Street 2:SUITE 25
Practice Address - City:GETTYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17325-2516
Practice Address - Country:US
Practice Address - Phone:717-337-4290
Practice Address - Fax:717-337-4295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-02
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50104776OtherCAPITAL BLUE CROSS-WMG
PAGRP#2675214OtherHIGHMARK BLUE SHIELD
PA1603060OtherGATEWAY
PA30105302OtherAMERIHEALTH MERCY - WMG
PA50104776OtherCAPITAL BLUE CROSS-WMG
PAGRP#2675214OtherHIGHMARK BLUE SHIELD