Provider Demographics
NPI:1770651804
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN FAMILY MEDICINE - LITTLESTOWN
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:717-359-4178
Practice Address - Street 1:300 W KING ST
Practice Address - Street 2:SUITE C
Practice Address - City:LITTLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:17340-1446
Practice Address - Country:US
Practice Address - Phone:717-339-2390
Practice Address - Fax:717-359-4178
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
PA1552819OtherGATEWAY
PA1848156OtherHIGHMARK BLUE SHIELD
PAS1EXOtherGEISINGER
PA20051562OtherAMERIHEALTH MERCY
PA7015846OtherAETNA
PACA3246OtherRAILROAD MEDICARE
PA50059430OtherCAPITAL BLUE CROSS
PA800174OtherJOHN HOPKINS
MDKX10OtherCAREFIRST MD BCBS
PA2706111001OtherAMERIHEALTH 65 PA
PA1007721360251Medicaid
PA183123OtherUNISON
PA1007721360251Medicaid
PA=========166OtherTRICARE