Provider Demographics
NPI:1942361506
Name:WELLSPAN MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:WELLSPAN INFECTIOUS DISEASE SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISOR-VERIFICATION SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
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:717-851-2417
Mailing Address - Fax:717-851-3712
Practice Address - Street 1:1001 S GEORGE ST
Practice Address - Street 2:MKB 4TH FLOOR
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-3676
Practice Address - Country:US
Practice Address - Phone:717-851-2417
Practice Address - Fax:717-851-3712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1948539OtherHIGHMARK
PA20055012OtherAMERIHEALTH MERCY
PA388TOtherGEISINGER
PA50059623OtherCAPITAL BLUE CROSS
PA1007721360253Medicaid
PA1554376OtherGATEWAY
MDKX54OtherCAREFIRST BCBS
PA0667146000OtherAMERIHEALTH 65 PA
PA800174OtherJOHN HOPKINS
PA7866894OtherAETNA
PACA3246OtherRAILROAD MEDICARE
PACA3246OtherRAILROAD MEDICARE
PA1554376OtherGATEWAY