Provider Demographics
NPI:1215994934
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:717-843-6682
Practice Address - Street 1:924 COLONIAL AVE STE B
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-3450
Practice Address - Country:US
Practice Address - Phone:717-845-8623
Practice Address - Fax:717-843-6682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA800174OtherJOHN HOPKINS
PA0068498001OtherAMERI 65PA COLONIAL
PA03005700OtherCAPITAL BLUE CROSS
PA1519824OtherGATEWAY
PA20010095OtherAMERIHEALTH GEORGE ST
PA1007721360092Medicaid
PA354TOtherGEISINGER SP
PAS1EMOtherGEISINGER PCP
PA0068498000OtherAMERI 65PA GEORGE ST
PA5126007OtherAETNA
PA059784OtherHIGHMARK BLUE SHIELD
PA100721360243Medicaid
PA82194OtherUNISON COLONIAL AVE
MDDJ3QOtherCAREFIRST MD BCBS
PA1142285OtherAMERIHEALTH COLONIAL AVE
PA82201OtherUNISON GEORGE ST
PACA3246OtherRAILROAD MEDICARE
PA5126007OtherAETNA
PA=========026OtherTRICARE COLONIAL AVE
PA20010095OtherAMERIHEALTH GEORGE ST