Healthcare Provider Details

I. General information

NPI: 1669644183
Provider Name (Legal Business Name): WELLSPAN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 11/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 S WASHINGTON ST SUITE C
GETTYSBURG PA
17325-2500
US

IV. Provider business mailing address

1803 MOUNT ROSE AVE SUITE B3
YORK PA
17403-3026
US

V. Phone/Fax

Practice location:
  • Phone: 717-339-3110
  • Fax: 717-339-3108
Mailing address:
  • Phone: 717-851-1405
  • Fax: 717-339-3108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: AMY F WILKINSON
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 717-851-1405