1972664068 NPI number — WELLSPAN MEDICAL GROUP

Table of content: (NPI 1972664068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972664068 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:
YORK PEDIATRIC 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:
1972664068
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:
17403-3051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-851-1405
Provider Business Mailing Address Fax Number:
717-846-8185

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2050 S QUEEN ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
YORK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17403-4829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-812-4240
Provider Business Practice Location Address Fax Number:
717-848-5520
Provider Enumeration Date:
12/12/2006

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 COORDINATOR
Authorized Official Telephone Number:
717-851-1405

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0068581001 . This is a "AMERIH65PA-QUEEN ST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1007721360101 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1519312 . This is a "GATEWAY-CARLISLE RD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1142399 . This is a "AMERIH MERCY-QUEEN ST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 82152 . This is a "UNISON" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: S1E5 . This is a "GEISINGER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1519311 . This is a "GATEWAY-QUEEN ST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 4509645 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 20005265 . This is a "AMERIH MERCY-CARLISLE RD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 455070 . 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: CA3246 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: KX53 . This is a "CAREFIRST MD BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 0068581003 . This is a "AMERIH65PA-CARLISLE RD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 03124100 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1007721360090 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".