Provider Demographics
NPI:1457439531
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN MATERNAL FETAL MEDICINE
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:717-851-3127
Practice Address - Street 1:35 MONUMENT RD
Practice Address - Street 2:SUITE 202
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-5074
Practice Address - Country:US
Practice Address - Phone:717-851-2722
Practice Address - Fax:717-851-3127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007721360263Medicaid
PA1520915OtherGATEWAY
PAKX03OtherCAREFIRST MD BCBS
PA5673117OtherAETNA
PACA3246OtherRAILROAD MEDICARE
PA02308800OtherCAPITAL BLUE CROSS
PA341TOtherGEISINGER HP
PA640230OtherHIGHMARK BLUE SHIELD
PA0510126000OtherAMERIHEALTH 65PA
PA1007721360128Medicaid
PA20010208OtherAMERIHEALTH MERCY
MD401065506Medicaid
MD401065508Medicaid
PA82209OtherUNISON
MD401065507Medicaid
PA1007721360242Medicaid
PA800174OtherJOHN HOPKINS HP
PA1007721360242Medicaid
PA20010208OtherAMERIHEALTH MERCY