Healthcare Provider Details

I. General information

NPI: 1811065626
Provider Name (Legal Business Name): WELLSPAN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 01/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 BANNISTER ST SUITE 1
YORK PA
17404-4946
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 717-812-2000
  • Fax: 717-812-2010
Mailing address:
  • Phone: 717-851-1405
  • Fax: 717-812-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. CHRISTINA VEST
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 717-851-1405