Healthcare Provider Details

I. General information

NPI: 1558468777
Provider Name (Legal Business Name): WELLSPAN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 S QUEEN ST
YORK PA
17403-4630
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 717-851-6110
  • Fax: 717-848-2074
Mailing address:
  • Phone: 717-851-1405
  • Fax: 717-851-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

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