Provider Demographics
NPI:1437227055
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN FAMILY MEDICINE - WHEATLYN
Other - Org Type:Doing Business As
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:717-851-6928
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:717-266-7453
Practice Address - Street 1:235 ROSEDALE DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:PA
Practice Address - Zip Code:17345-1022
Practice Address - Country:US
Practice Address - Phone:717-812-5229
Practice Address - Fax:717-266-7453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007721360087Medicaid
PA03058800OtherCAPITAL BLUE CROSS
PA1519817OtherGATEWAY
PA0083498001OtherAMERIHEALTH 65 PA
PA142576OtherHIGHMARK BLUE SHIELD
PA800174OtherJOHN HOPKINS
PA82198OtherUNISON
PA1142444OtherAMERIHEALTH MERCY
PA5525074OtherAETNA
PACA3246OtherRAILROAD MEDICARE
MDKX10OtherCAREFIRST MD BCBS
PAS1E4OtherGEISINGER
PA142576OtherHIGHMARK BLUE SHIELD
PA0083498001OtherAMERIHEALTH 65 PA