1346488764 NPI number — WELLSPAN MEDICAL GROUP

Table of content: (NPI 1346488764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346488764 NPI number — WELLSPAN MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLSPAN MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WELLSPAN SURGICAL ONCOLOGY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346488764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1803 MOUNT ROSE AVE
Provider Second Line Business Mailing Address:
SUITE B3
Provider Business Mailing Address City Name:
YORK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17403-3026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-851-1405
Provider Business Mailing Address Fax Number:
717-741-8217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 MONUMENT RD
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
YORK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17403-5049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-812-7676
Provider Business Practice Location Address Fax Number:
717-812-5176
Provider Enumeration Date:
01/22/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WILKINSON
Authorized Official First Name:
AMY
Authorized Official Middle Name:
F
Authorized Official Title or Position:
CREDENTIALING SUPERVISOR
Authorized Official Telephone Number:
717-851-1405

Provider Taxonomy Codes

  • Taxonomy code: 2086X0206X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100772136 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1578610 . This is a "GATEWAY-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 9095312 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50083176 . This is a "CAPITAL BLUE CROSS-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2086650 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 20082423 . This is a "AMERIHEALTH MERCY-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 261028 . This is a "UNISON-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: F0WKWE . This is a "CAREFIRST MD BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".