Provider Demographics
NPI:1275601676
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN FAMILY MEDICINE - HERR'S RIDGE
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:717-337-4411
Practice Address - Street 1:820 CHAMBERSBURG RD
Practice Address - Street 2:
Practice Address - City:GETTYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17325-3310
Practice Address - Country:US
Practice Address - Phone:717-337-4410
Practice Address - Fax:717-337-4411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1520445OtherGATEWAY
PA7865863OtherAETNA
PACA3246OtherRAILROAD MEDICARE
PA800174OtherJOHN HOPKINS
MDKX10OtherCAREFIRST MD BCBS
PAS1FBOtherGEISINGER
PA03273300OtherCAPITAL BLUE CROSS
PA130452OtherUNISON
PA20013070OtherAMERIHEALTH MERCY
PA0404995001OtherAMERIHEALTH 65 PA
PA1382344OtherHIGHMARK BLUE SHIELD
MD401065502OtherMD MEDICAL ASSISTANCE
PA1007721360127Medicaid
PA7865863OtherAETNA
PA800174OtherJOHN HOPKINS