Provider Demographics
NPI:1811065626
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:717-812-2010
Practice Address - Street 1:1575 BANNISTER ST
Practice Address - Street 2:SUITE 1
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17404-4946
Practice Address - Country:US
Practice Address - Phone:717-812-2000
Practice Address - Fax:717-812-2010
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 - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007721360094Medicaid
PA1519300OtherGATEWAY
MDKX10OtherCAREFIRST MD BCBS
PA03006400OtherCAPITAL BLUE CROSS
PA107496OtherHIGHMARK BLUE SHIELD
PA4474210OtherAETNA
PA800174OtherJOHN HOPKINS
PA82186OtherUNISON
PACA3246OtherRAILROAD MEDICARE
PAS1E6OtherGEISINGER
PA0068841001OtherAMERIHEALTH 65 PA
PA1142406OtherAMERIHEALTH MERCY
PA1519300OtherGATEWAY
PA82186OtherUNISON