Provider Demographics
NPI:1184784704
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:717-334-6659
Practice Address - Street 1:40 V TWIN DR STE 204
Practice Address - Street 2:
Practice Address - City:GETTYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17325-7878
Practice Address - Country:US
Practice Address - Phone:717-339-2424
Practice Address - Fax:717-334-6659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA03150800OtherCAPITAL BLUE CROSS
PA800174OtherJOHN HOPKINS
PA132618OtherUNISON
PA20013267OtherAMERIHEALTH MERCY
PA5092062OtherAETNA
PA2073720001OtherAMERIHEALTH 65 PA
PACA3246OtherRAILROAD MEDICARE
PA1007721360120Medicaid
PA1382342OtherHIGHMARK
PA1512287OtherGATEWAY
MDKX54OtherCAREFIRST BCBS
PAS1FCOtherGEISINGER HEALTHPLAN
PA03150800OtherCAPITAL BLUE CROSS
PA1007721360120Medicaid