1770651804 NPI number — WELLSPAN MEDICAL GROUP

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770651804 NPI number — WELLSPAN MEDICAL GROUP

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 Other Organization Name:

Provider Other Organization Name Type Code:

6

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:

1770651804

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

01/11/2018

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

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:

717-359-4178

Provider First Line Business Practice Location Address:

300 W KING ST

Provider Second Line Business Practice Location Address:

SUITE C

Provider Business Practice Location Address City Name:

LITTLESTOWN

Provider Business Practice Location Address State Name:

PA

Provider Business Practice Location Address Postal Code:

17340-1446

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

717-339-2390

Provider Business Practice Location Address Fax Number:

717-359-4178

Provider Enumeration Date:

11/30/2006

Authorized Official Last Name:

VEST

Authorized Official First Name:

CHRISTINA

Authorized Official Middle Name:

Authorized Official Title or Position:

CREDENTIALING SUPERVISOR

Authorized Official Telephone Number:

717-851-1405

• Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 1552819 . This is a "GATEWAY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 1848156 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: S1EX . This is a "GEISINGER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 20051562 . This is a "AMERIHEALTH MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 7015846 . This is a "AETNA" 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: 50059430 . This is a "CAPITAL BLUE CROSS" 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: KX10 . This is a "CAREFIRST MD BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 2706111001 . This is a "AMERIHEALTH 65 PA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 1007721360251 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
• Identifier: 183123 . This is a "UNISON" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".