Provider Demographics
NPI:1821159021
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN NEPHROLOGY
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 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-851-6040
Mailing Address - Fax:717-812-3190
Practice Address - Street 1:380 SAINT CHARLES WAY
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-4647
Practice Address - Country:US
Practice Address - Phone:717-851-6040
Practice Address - Fax:717-812-3190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0667146000OtherAMERIHEALTH 65PA
MD522COtherCAREFIRST BCBS
PA1007721360254Medicaid
PACA3246OtherRAILROAD MEDICARE
PA50055987OtherCAPITAL BLUE CROSS
PA20047687OtherAMERIHEALTH MERCY
PA800174OtherJOHN HOPKINS
PA7579839OtherAETNA
PA117038OtherHIGHMARK BLUES SHIELD
PA340TOtherGEISINGER
PA1548225OtherGATEWAY
PA800174OtherJOHN HOPKINS
PA1007721360254Medicaid