Provider Demographics
NPI:1659449031
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN FAMILY MEDICINE - PLYMOUTH RD
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:717-851-1810
Practice Address - Street 1:1010 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-3864
Practice Address - Country:US
Practice Address - Phone:717-851-1800
Practice Address - Fax:717-851-1810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0202925002OtherAMERIHEALTH 65 PA
PA5203300OtherAETNA
PA1007721360099Medicaid
PA1142354OtherAMERIHEALTH MERCY
PAS1ESOtherGEISINGER
MDKX10OtherCAREFIRST MD BCBS
PA1519295OtherGATEWAY
PA800174OtherJOHN HOPKINS
PA02293800OtherCAPITAL BLUE CROSS
PA501286OtherHIGHMARK BLUE SHIELD
PA82193OtherUNISON
PACA3246OtherRAILROAD MEDICARE
PA1007721360099Medicaid
PA82193OtherUNISON