Provider Demographics
NPI:1093443533
Name:WELLNITE MEDICAL GROUP PA
Entity Type:Organization
Organization Name:WELLNITE MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALANSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-644-6008
Mailing Address - Street 1:2261 MARKET ST # 4058
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-1612
Mailing Address - Country:US
Mailing Address - Phone:855-731-1410
Mailing Address - Fax:
Practice Address - Street 1:11811 SHAKER BLVD STE 204
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-1931
Practice Address - Country:US
Practice Address - Phone:341-888-7637
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-11
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty