1073756672 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 1073756672 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 PULMONARY AND SLEEP MEDICINE
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:
1073756672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 MEMORY LN STE B3
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:
17402-2231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-851-1405
Provider Business Mailing Address Fax Number:
717-741-3043

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2350 FREEDOM WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YORK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17402-8200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-851-2465
Provider Business Practice Location Address Fax Number:
717-741-3043
Provider Enumeration Date:
04/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BUCZKOWSKI
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
EVP AND CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
410-259-0783

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RS0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1581228 . This is a "GATEWAY-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 100772136 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2108539 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 9930316 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 20087275 . This is a "AMERIHEALTH MERCY-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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