Provider Demographics
NPI:1265952998
Name:WELLSPRING FAMILY MEDICINE, PC
Entity type:Organization
Organization Name:WELLSPRING FAMILY MEDICINE, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RAMONA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-501-5110
Mailing Address - Street 1:311 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21550-1371
Mailing Address - Country:US
Mailing Address - Phone:301-334-7855
Mailing Address - Fax:301-334-7828
Practice Address - Street 1:311 N 4TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-1371
Practice Address - Country:US
Practice Address - Phone:301-334-7855
Practice Address - Fax:301-334-7828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD120141041C0700X, 1041C0700X
MD05746103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD413901100Medicaid
WV3810006442Medicaid