Healthcare Provider Details

I. General information

NPI: 1700567260
Provider Name (Legal Business Name): WELLSPAN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8131 SPYGLASS HILL DR
FAYETTEVILLE PA
17222-5500
US

IV. Provider business mailing address

3421 CONCORD RD
YORK PA
17402-9001
US

V. Phone/Fax

Practice location:
  • Phone: 717-264-5211
  • Fax: 717-264-5418
Mailing address:
  • Phone: 717-851-1405
  • Fax: 717-851-6969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: LAURA FRANK
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 717-851-6832