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General NPI Number Information
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NPI Number | 1740835560
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Entity Type | Organization
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Legal Business Name | WELLSPAN MEDICAL GROUP
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Dates
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Enumeration Date | 08/08/2019
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Last Update Date | 08/08/2019
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Provider Practice Location Address
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Address Line | 1401 ROOSEVELT AVE
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City | YORK
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State | PA
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Zip | 17404-2244
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Country | US
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Telephone | 717-812-4253
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Fax | 717-461-7436
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Provider Business Mailing Address
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Address Line | 3421 CONCORD RD
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City | YORK
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State | PA
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Zip | 17402-9001
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Country | US
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Telephone | 717-851-1405
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Fax | 717-851-6969
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Authorized Official
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Title or Position | SUPERVISOR OF CREDENTIALING
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Name | JULIANN DIAZ
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Credential |
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Telephone | 717-851-7134
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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