Provider Demographics
NPI:1245308634
Name:WELLSPAN MEDICAL GROUP
Entity type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:717-845-4625
Practice Address - Street 1:2775 N GEORGE ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17406-3020
Practice Address - Country:US
Practice Address - Phone:717-812-7300
Practice Address - Fax:717-845-4625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
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
PA1007721360250Medicaid
PA1142379OtherAMERIHEALTH MERCY
PA0153205002OtherAMERIHEALTH 65 PA
PA1519816OtherGATEWAY
PA5861335OtherAETNA
PACA3246OtherRAILROAD MEDICARE
PA82796OtherUNISON
PAS1EVOtherGEISINGER
PA800174OtherJOHN HOPKINS
MDKX10OtherCAREFIRST MD BCBS
PA02297900OtherCAPITAL BLUE CROSS
PA968315OtherHIGHMARK BLUE SHIELD
PA02297900OtherCAPITAL BLUE CROSS
PA1007721360250Medicaid