Provider Demographics
NPI:1245490515
Name:WELLSPAN MEDICAL GROUP
Entity type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:F
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-851-1401
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:717-812-6700
Mailing Address - Fax:717-741-2927
Practice Address - Street 1:50 WYNTRE BROOKE DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-4535
Practice Address - Country:US
Practice Address - Phone:717-812-6700
Practice Address - Fax:717-741-2927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1571819OtherGATEWAY-WMG
PA100772136Medicaid
PA2047084OtherHIGHMARK BLUE SHIELD
PA9175206OtherAETNA
PA171COtherGEISINGER HEALTH PLAN
MDFS72OtherCAREFIRST MD BCBS
PA50078670OtherCAPITAL BLUE CROSS-WMG
PA20076067OtherAMERIHEALTH MERCY-WMG
PA117038FLTMedicare PIN