Healthcare Provider Details

I. General information

NPI: 1265591481
Provider Name (Legal Business Name): WELLSPAN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PINE GROVE COMMONS
YORK PA
17403-5176
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 717-812-2143
  • Fax: 717-812-2163
Mailing address:
  • Phone: 717-851-1405
  • Fax: 717-812-2163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

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