Provider Demographics
NPI:1326116823
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN FAMILY MEDICINE - DALLASTOWN
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:717-851-1310
Practice Address - Street 1:755 S PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:DALLASTOWN
Practice Address - State:PA
Practice Address - Zip Code:17313-9252
Practice Address - Country:US
Practice Address - Phone:717-851-1300
Practice Address - Fax:717-851-1310
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 - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0068835003OtherAMERIHEALTH 65 PA
PA1142363OtherAMERIHEALTH MERCY
PA800174OtherJOHN HOPKINS
PA099048OtherHIGHMARK BLUE SHIELD
PA1519304OtherGATEWAY
PA02297500OtherCAPITAL BLUE CROSS
PA82148OtherUNISON
PACA3246OtherRAILROAD MEDICARE
MDKX10OtherCAREFIRST MD BCBS
PA5161031OtherAETNA
PA1007721360085Medicaid
PAS1EPOtherGEISINGER
PA1007721360085Medicaid
PA82148OtherUNISON