Provider Demographics
NPI:1629139621
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN OB/GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERISOR-VERIFICATION SERVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-851-1405
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-812-2316
Mailing Address - Fax:717-848-5540
Practice Address - Street 1:2050 S QUEEN ST
Practice Address - Street 2:STE 200
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-4829
Practice Address - Country:US
Practice Address - Phone:717-812-2316
Practice Address - Fax:717-848-5540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Single Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1142781OtherAMERIHEALTH MERCY
PA82325OtherUNISON
PACA3246OtherRAILROAD MEDICARE
PA0068402000OtherAMERIHEALTH 65PA
PA1007721360098Medicaid
PA1007721360115Medicaid
PA4473686OtherAETNA
PA03007400OtherCAPITAL BLUE CROSS
PA028645OtherHIGHMARK BLUE SHIELD
PA1519820OtherGATEWAY
MDKX03OtherCAREFIRST
PA800174OtherJOHN HOPKINS
PA1007721360096Medicaid
PA1007721360112Medicaid
PA03007400OtherCAPITAL BLUE CROSS
PA=========073OtherTRICARE QUEEN ST
PA1519820OtherGATEWAY
PA=========017OtherTRICARE LINCOLN HWY
PA=========100OtherTRICARE WOLFE ROAD
PA=========073OtherTRICARE QUEEN ST