Provider Demographics
NPI:1093883084
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN INTERNAL MEDICINE - APPLE HILL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-851-1405
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-851-1405
Mailing Address - Fax:717-741-8016
Practice Address - Street 1:25 MONUMENT RD
Practice Address - Street 2:SUITE 140
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-5057
Practice Address - Country:US
Practice Address - Phone:717-741-8003
Practice Address - Fax:717-741-8016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2016-09-29
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
MDKX54OtherCAREFIRST MD BCBS
PA02294100OtherCAPITAL BLUE CROSS
PA1007721360089Medicaid
PA1142277OtherAMERIHEALTH
PA30094417OtherAMERIHEALTH MERCY - WMG
PA756142001OtherAMERIHEALTH 65 PA
PA800174OtherJOHN HOPKINS
PAS1EKOtherGEISINGER
PA1519305OtherGATEWAY
PA595252OtherHIGHMARK BLUE SHIELD
PA5669051OtherAETNA
PA82750OtherUNISON
PACA3246OtherRAILROAD MEDICARE
PA5669051OtherAETNA
PAS1EKOtherGEISINGER