Provider Demographics
NPI:1790853695
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN FAMILY MEDICINE - FAIRFIELD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CVO-MANAGER
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:717-851-1405
Mailing Address - Fax:717-255-0950
Practice Address - Street 1:4910A FAIRFIELD RD STE A
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:PA
Practice Address - Zip Code:17320-9201
Practice Address - Country:US
Practice Address - Phone:717-339-3175
Practice Address - Fax:717-255-0950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007721360126Medicaid
PA20013074OtherAMERIHEALTH MERCY
MD401065503OtherMARYLAND MEDICAID
PA7579833OtherAETNA
PAS1ETOtherGEISINGER
PA1382350OtherHIGHMARK BLUE SHIELD
PA1527201OtherGATEWAY
PA2073722002OtherAMERIHEALTH 65 PA
PA800174OtherJOHN HOPKINS
PA130408OtherUNISON
MD462MOtherMARYLAND MEDICARE
PACA3246OtherRAILROAD
PA03181900OtherCAPITAL BLUE CROSS
PA7579833OtherAETNA
PAS1ETOtherGEISINGER