Provider Demographics
NPI:1679667679
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
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:717-851-1405
Mailing Address - Fax:
Practice Address - Street 1:2250 E MARKET ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-2857
Practice Address - Country:US
Practice Address - Phone:717-812-3940
Practice Address - Fax:717-812-3950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50062674OtherCAPITAL BLUE CROSS
PA7594870OtherAETNA
PA1007721360262Medicaid
PA800174OtherJOHN HOPKINS WELLSPAN MG
PACA3246OtherRAILROAD MEDICARE
PA1874423OtherHIGHMARK WELLSPAN MG
MD19WWOtherCAREFIRST BCBS
PA417TOtherGEISINGER
PA20054647OtherAMERIHEALTH MERCY
PA2736586000OtherAMERIHEALTH 65PA
PACA3246OtherRAILROAD MEDICARE
PA417TOtherGEISINGER
PA1874423OtherHIGHMARK WELLSPAN MG