Provider Demographics
NPI:1750480299
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN PALLIATIVE AND SUPPORTIVE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANK
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:717-338-4525
Mailing Address - Fax:
Practice Address - Street 1:423 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GETTYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17325-2526
Practice Address - Country:US
Practice Address - Phone:717-338-4525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No2084H0002XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyHospice and Palliative MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50062335OtherCAPITAL BLUE CROSS
PA7236812OtherAETNA
PA1933923OtherHIGHMARK
PACA3246OtherRAILROAD MEDICARE
PA800174OtherJOHN HOPKINS
PA189919OtherUNISON
PA1007721360259Medicaid
PA20055972OtherAMERIHEALTH MERCY
PA434TOtherGEISINGER
PA50062335OtherCAPITAL BLUE CROSS
PA=========171OtherTRICARE
PA50062335OtherCAPITAL BLUE CROSS
PA800174OtherJOHN HOPKINS
PA0667146000OtherAMERIHEALTH 65PA