Provider Demographics
NPI:1093882144
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN INTERNAL MEDICINE - RED LION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:VEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-851-1405
Mailing Address - Street 1:1803 MOUNT ROSE AVE
Mailing Address - Street 2:SUITE B3
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17403-3051
Mailing Address - Country:US
Mailing Address - Phone:717-851-1405
Mailing Address - Fax:717-851-1710
Practice Address - Street 1:3065 WINDSOR RD
Practice Address - Street 2:
Practice Address - City:RED LION
Practice Address - State:PA
Practice Address - Zip Code:17356-8533
Practice Address - Country:US
Practice Address - Phone:717-851-1700
Practice Address - Fax:717-851-1710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAS1EUOtherGEISINGER
PA0068508002OtherAMERIHEALTH 65 PA
PA4624959OtherAETNA
MDKX54OtherCAREFIRST MD BCBS
PA111191OtherHIGHMARK BLUE SHIELD
PA1142361OtherAMERIHEALTH MERCY
PA800174OtherJOHN HOPKINS
PA02301800OtherCAPITAL BLUE CROSS
PA1007721360093Medicaid
PACA3246OtherRAILROAD MEDICARE
PA1519310OtherGATEWAY
PA82238OtherUNISON
PA0068508002OtherAMERIHEALTH 65 PA
PA=========041OtherTRICARE