1669770004 NPI number — WELLSPAN MEDICAL GROUP

Table of content: (NPI 1669770004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669770004 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 GASTROENTEROLOGY
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:
1669770004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2015
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:
717-741-9633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2350 FREEDOM WAY
Provider Second Line Business Practice Location Address:
SUITE 200
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:
717-812-5120
Provider Business Practice Location Address Fax Number:
717-741-3075
Provider Enumeration Date:
03/09/2011

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:
717-812-5120

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 50099585 . This is a "CAPITAL BLUE CROSS-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2598649 . This is a "HIGHMARK BLUE SHIELD-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: C8J5 . This is a "CAREFIRST MD BCBS-WMG" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1007721360299 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1593952 . This is a "GATEWAY-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 9203695 . This is a "AETNA-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 30088992 . This is a "AMERIHEALTH MERCY-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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