MEDICARE: WELLSPAN MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207T00000X	Neurological Surgery Physician

General Provider Information

NPI Number	:	1548735103
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLSPAN MEDICAL GROUP

Provider Business Mailing Address
First Line	:	3421 CONCORD RD
Second Line	:
City	:	YORK
State	:	PA
Zip	:	17402-9001
Country	:	US
Telephone Number	:	717-851-1566
Fax Number	:	717-812-3950

Provider Business Practice Location Address
First Line	:	4150 BARRETT BLVD
Second Line	:
City	:	EPHRATA
State	:	PA
Zip	:	17522-8979
Country	:	US
Telephone Number	:	717-466-2505
Fax Number	:	717-466-2506

Authorized Official
Title or Position	:	CREDENTIALING SUPERVISOR
Name	:	CHRISTINA VEST
Credential	:
Telephone Number	:	717-851-6928

Provider Enumeration Date	:	10/10/2018
Last Update Date	:	10/10/2018

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