Provider Demographics
NPI:1265591481
Name:WELLSPAN MEDICAL GROUP
Entity type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:717-812-2163
Practice Address - Street 1:300 PINE GROVE COMMONS
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-5176
Practice Address - Country:US
Practice Address - Phone:717-812-2143
Practice Address - Fax:717-812-2163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA800174OtherJOHN HOPKINS
PA1007721360258Medicaid
MDKX54OtherCAREFIRST MD BCBS
PA50023472OtherCAPITAL BLUE CROSS
PA1471291OtherHIGHMARK BLUE SHIELD
PA1531858OtherGATEWAY
PA20022918OtherAMERIHEALTH MERCY
PA2155344001OtherAMERIHEALTH 65 PA
PA7689843OtherAETNA
PAS1EYOtherGEISINGER
PACA3246OtherRAILROAD MEDICARE
PA=========125OtherTRICARE
PAS1EYOtherGEISINGER