Provider Demographics
NPI:1114088408
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
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:717-851-6301
Practice Address - Street 1:25 MONUMENT RD STE 105
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-5049
Practice Address - Country:US
Practice Address - Phone:717-851-7575
Practice Address - Fax:717-812-5154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity MedicineGroup - Single Specialty
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA152996OtherUNISON MUZZIO
PA20036194OtherAMERIHEALTH MERCY
PA1946212OtherHIGHMARK
PA800174OtherJOHN HOPKINS
PACA3246OtherRAILROAD MEDICARE
PA169903OtherUNISON TURKEWITZ
PA356TOtherGEISINGER
PA756142008OtherAMERIHEALTH 65 PA
PA1007721360252Medicaid
MDKX54OtherCAREFIRST BCBS
PA50041721OtherCAPITAL BLUE CROSS
PA7254857OtherAETNA
PA756142008OtherAMERIHEALTH 65 PA
PA152996OtherUNISON MUZZIO