Healthcare Provider Details

I. General information

NPI: 1790315653
Provider Name (Legal Business Name): WELLSPAN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2020
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MONUMENT RD STE 297
YORK PA
17403-5049
US

IV. Provider business mailing address

3421 CONCORD RD
YORK PA
17402-9001
US

V. Phone/Fax

Practice location:
  • Phone: 717-741-6732
  • Fax: 717-740-6058
Mailing address:
  • Phone: 717-851-1405
  • Fax: 717-851-6969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

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