1104988740 NPI number — WELLSPAN MEDICAL GROUP

Table of content: (NPI 1104988740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104988740 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 CARDIOTHORACIC SURGERY
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:
1104988740
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2021
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:
717-851-6454
Provider Business Mailing Address Fax Number:
717-851-1665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 MONUMENT ROAD
Provider Second Line Business Practice Location Address:
SUITE 1100
Provider Business Practice Location Address City Name:
YORK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17403-5024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-851-6454
Provider Business Practice Location Address Fax Number:
717-851-1665
Provider Enumeration Date:
12/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FRANK
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER-VERIFICATION SERVICES
Authorized Official Telephone Number:
717-851-6832

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1536225 . This is a "GATEWAY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 401065514 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: ========= . This is a "TRICARE WASHINGTON ST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: CA3246 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 344T . This is a "GEISINGER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50039030 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7619892 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1007721360246 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20034217 . This is a "AMERIHEALTH MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1007721360105 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2305610000 . This is a "AMERIHEALTH 65PA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1628553 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 800174 . This is a "JOHN HOPKINS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 04P5 . This is a "CAREFIRST MD BCBS-STE 190" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: ========= . This is a "TRICARE BANNISTER ST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: KC94 . This is a "CAREFIRST BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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