Provider Demographics
NPI:1760550883
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN FAMILY MEDICINE - VALLEY GREEN
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:717-938-9601
Practice Address - Street 1:1790 OLD TRAIL RD
Practice Address - Street 2:
Practice Address - City:ETTERS
Practice Address - State:PA
Practice Address - Zip Code:17319-9600
Practice Address - Country:US
Practice Address - Phone:717-938-6588
Practice Address - Fax:717-938-9601
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 - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1519864OtherGATEWAY
PA2018600001OtherAMERIHEALTH 65 PA
PA1325425OtherHIGHMARK BLUE SHIELD
PA7293846OtherAETNA
PA800174OtherJOHN HOPKINS
PA1007721360133Medicaid
PAS1E3OtherGEISINGER
PACA3246OtherRAILROAD MEDICARE
PA02318100OtherCAPITAL BLUE CROSS
PA20010015OtherAMERIHEALTH MERCY
MDKX10OtherCAREFIRST MD BCBS
MDKX10OtherCAREFIRST MD BCBS
PA=========103OtherTRICARE