Provider Demographics
NPI:1114292760
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN FAMILY MEDICINE - FREDERICK ST
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:17403-3026
Mailing Address - Country:US
Mailing Address - Phone:717-851-6816
Mailing Address - Fax:717-632-7478
Practice Address - Street 1:100 FREDERICK ST
Practice Address - Street 2:SUITE 101
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-3518
Practice Address - Country:US
Practice Address - Phone:717-851-7050
Practice Address - Fax:717-632-7478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-15
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA30112625OtherAMERIHEALTH MERCY - WMG
PA9886818OtherAETNA
PA2695421OtherHIGHMARK BLUE SHIELD
PA50107968OtherCAPITAL BLUE CROSS - WMG
PA1603334OtherGATEWAY HEALTH PLAN
PA30112625OtherAMERIHEALTH MERCY - WMG
PA9886818OtherAETNA