1033660550 NPI number — WELLSPAN MEDICAL GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033660550 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 FAMILY MEDICINE - MEADOWBROOK
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:
1033660550
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3421 CONCORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YORK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17402-9001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-851-1405
Provider Business Mailing Address Fax Number:
717-851-6969

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
368 W MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LEOLA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17540-1761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-656-6122
Provider Business Practice Location Address Fax Number:
717-656-0142
Provider Enumeration Date:
10/19/2016

Additional Information

Authorized Official

Authorized Official Last Name:
FRANK
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
CVS-MANAGER
Authorized Official Telephone Number:
717-851-1405

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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