Provider Demographics
NPI:1972664068
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:717-846-8185
Practice Address - Street 1:2050 S QUEEN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-4829
Practice Address - Country:US
Practice Address - Phone:717-812-4240
Practice Address - Fax:717-848-5520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0068581001OtherAMERIH65PA-QUEEN ST
PA1007721360101Medicaid
PA1519312OtherGATEWAY-CARLISLE RD
PA1142399OtherAMERIH MERCY-QUEEN ST
PA82152OtherUNISON
PAS1E5OtherGEISINGER
PA1519311OtherGATEWAY-QUEEN ST
PA4509645OtherAETNA
PA20005265OtherAMERIH MERCY-CARLISLE RD
PA455070OtherHIGHMARK BLUE SHIELD
PA800174OtherJOHN HOPKINS
PACA3246OtherRAILROAD MEDICARE
MDKX53OtherCAREFIRST MD BCBS
PA0068581003OtherAMERIH65PA-CARLISLE RD
PA03124100OtherCAPITAL BLUE CROSS
PA1007721360090Medicaid
PA800174OtherJOHN HOPKINS
PA82152OtherUNISON
PA20005265OtherAMERIH MERCY-CARLISLE RD