Healthcare Provider Details

I. General information

NPI: 1184962821
Provider Name (Legal Business Name): WELLSPAN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2013
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1227 BALTIMORE ST
HANOVER PA
17331-4406
US

IV. Provider business mailing address

1803 MOUNT ROSE AVE STE B3
YORK PA
17403-3051
US

V. Phone/Fax

Practice location:
  • Phone: 717-812-5190
  • Fax: 717-637-2245
Mailing address:
  • Phone: 717-851-1405
  • Fax: 717-637-2245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. LAURA FRANK
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 717-851-1405