=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114292760
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLSPAN MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2012
-----------------------------------------------------
Last Update Date | 01/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 FREDERICK ST SUITE 101
-----------------------------------------------------
City | HANOVER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17331-3518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-851-7050
-----------------------------------------------------
Fax | 717-632-7478
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1803 MOUNT ROSE AVE SUITE B3
-----------------------------------------------------
City | YORK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17403-3026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-851-6816
-----------------------------------------------------
Fax | 717-632-7478
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SUPERVISOR
-----------------------------------------------------
Name | MS. CHRISTINA VEST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 717-851-1405
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------