Healthcare Provider Details

I. General information

NPI: 1215994934
Provider Name (Legal Business Name): WELLSPAN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 08/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

924 COLONIAL AVE STE B
YORK PA
17403-3450
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 717-845-8623
  • Fax: 717-843-6682
Mailing address:
  • Phone: 717-851-1405
  • Fax: 717-843-6682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. AMY F WILKINSON
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 717-851-1405