Healthcare Provider Details

I. General information

NPI: 1780839167
Provider Name (Legal Business Name): WELLSPAN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2008
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MONUMENT RD SUITE 290
YORK PA
17403-5073
US

IV. Provider business mailing address

1803 MOUNT ROSE AVE SUITE B3
YORK PA
17403-3026
US

V. Phone/Fax

Practice location:
  • Phone: 717-812-4090
  • Fax: 717-812-4092
Mailing address:
  • Phone: 717-851-1405
  • Fax: 717-812-4092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. AMY F WILKINSON
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 717-851-1401