Provider Demographics
NPI:1538266598
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:717-337-4324
Practice Address - Street 1:450 S WASHINGTON ST
Practice Address - Street 2:SUITE B
Practice Address - City:GETTYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17325-2500
Practice Address - Country:US
Practice Address - Phone:717-337-4492
Practice Address - Fax:717-337-4324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2073725002OtherAMERIHEALTH 65 PA
PA02530300OtherCAPITAL BLUE CROSS
PA1007721360138Medicaid
PA7596360OtherAETNA
PA1382358OtherHIGHMARK
PA115409OtherUNISON
PA800174OtherJOHN HOPKINS
MDKX03OtherCAREFIRST
PA1520724OtherGATEWAY
PA336TOtherGEISINGER
MD401065500Medicaid
PA20013079OtherAMERIHEALTH MERCY
PA02530300OtherCAPITAL BLUE CROSS
PA2073725002OtherAMERIHEALTH 65 PA
PA1242630009Medicare NSC