Provider Demographics
NPI:1710055819
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN FAMILY MEDICINE - STONY BROOK
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:717-812-2052
Practice Address - Street 1:4222 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17406-8083
Practice Address - Country:US
Practice Address - Phone:717-812-2050
Practice Address - Fax:717-812-2052
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
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007721360117Medicaid
PA1142436OtherAMERIHEALTH MERCY
PA800174OtherJOHN HOPKINS
PAS1E2OtherGEISINGER
PA82195OtherUNISON
PA597333OtherHIGHMARK BLUE SHIELD
MDKX10OtherCAREFIRST MD BCBS
PACA3246OtherRAILROAD MEDICARE
PA1519297OtherGATEWAY
PA02314700OtherCAPITAL BLUE CROSS
PA0756904001OtherAMERIHEALTH 65 PA
PA02314700OtherCAPITAL BLUE CROSS
PAS1E2OtherGEISINGER