1154872661 NPI number — WELLSPAN MEDICAL GROUP

Table of content: (NPI 1154872661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154872661 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 & PEDIATRIC MEDICINE - ROTHSVILLE
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:
1154872661
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2016
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:
2320 ROTHSVILLE RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LITITZ
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17543-8215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-721-4800
Provider Business Practice Location Address Fax Number:
717-626-1613
Provider Enumeration Date:
10/19/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MOON
Authorized Official First Name:
CHRISTINA
Authorized Official Middle Name:
Authorized Official Title or Position:
SUPERVISOR-VERIFICATION SERVICES
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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