Provider Demographics
NPI:1417739038
Name:WELLNITE MEDICAL GROUP PA
Entity Type:Organization
Organization Name:WELLNITE MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-731-1410
Mailing Address - Street 1:2261 MARKET ST # 4058
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-1612
Mailing Address - Country:US
Mailing Address - Phone:855-731-1410
Mailing Address - Fax:
Practice Address - Street 1:1105 2ND ST S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3911
Practice Address - Country:US
Practice Address - Phone:650-761-9770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty