Provider Demographics
NPI:1619044880
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN INTERNAL MEDICINE - DOVER
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:717-851-6400
Mailing Address - Fax:717-851-6410
Practice Address - Street 1:4020 CARLISLE RD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:PA
Practice Address - Zip Code:17315-3508
Practice Address - Country:US
Practice Address - Phone:717-851-6400
Practice Address - Fax:717-851-6410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0301664001OtherAMERIHEALTH 65 PA
PACA3246OtherRAILROAD MEDICARE
MDKX54OtherCAREFIRST MD BCBS
PA1007721360106Medicaid
PA7368911OtherAETNA
PA86448OtherUNISON
PA02293900OtherCAPITAL BLUE CROSS
PAS1EQOtherGEISINGER
PA1519815OtherGATEWAY
PA800174OtherJOHN HOPKINS
PA066330OtherHIGHMARK BLUE SHIELD
PA1142384OtherAMERIHEALTH MERCY
PA800174OtherJOHN HOPKINS
PACA3246OtherRAILROAD MEDICARE