Provider Demographics
NPI:1801954276
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:717-851-6577
Practice Address - Street 1:296 ST. CHARLES WAY
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-4648
Practice Address - Country:US
Practice Address - Phone:717-851-6567
Practice Address - Fax:717-851-6577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0021280001OtherAMERIHEALTH 65 PA
PA02293500OtherCAPITAL BLUE CROSS
PA1007721360132Medicaid
PA84533OtherUNISON
PA1142430OtherAMERIHEALTH MERCY
PACA3246OtherRAILROAD MEDICARE
PA369120OtherHIGHMARK BLUE SHIELD
PA800174OtherJOHN HOPKINS
MDKX54OtherCAREFIRST MD BCBS
PAS1EZOtherGEISINGER
PA1519314OtherGATEWAY
PA5894771OtherAETNA
PA1007721360132Medicaid
PA02293500OtherCAPITAL BLUE CROSS