Healthcare Provider Details

I. General information

NPI: 1588114094
Provider Name (Legal Business Name): WELLSPAN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2016
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 LAKE ST
EPHRATA PA
17522-2415
US

IV. Provider business mailing address

3421 CONCORD RD
YORK PA
17402-9001
US

V. Phone/Fax

Practice location:
  • Phone: 717-721-7718
  • Fax: 717-721-7726
Mailing address:
  • Phone: 717-851-1405
  • Fax: 717-851-6969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA MOON
Title or Position: SUPERVISOR-VERIFICATION SERVICES
Credential:
Phone: 717-851-1405