=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780839167
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLSPAN MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2008
-----------------------------------------------------
Last Update Date | 12/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 MONUMENT RD SUITE 290
-----------------------------------------------------
City | YORK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17403-5073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-812-4090
-----------------------------------------------------
Fax | 717-812-4092
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1803 MOUNT ROSE AVE SUITE B3
-----------------------------------------------------
City | YORK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17403-3026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-851-1405
-----------------------------------------------------
Fax | 717-812-4092
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SUPERVISOR
-----------------------------------------------------
Name | MS. AMY F WILKINSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 717-851-1401
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0801X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Trauma Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------