Provider Demographics
NPI:1881762995
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:301-271-2650
Practice Address - Street 1:52 WATER ST
Practice Address - Street 2:
Practice Address - City:THURMONT
Practice Address - State:MD
Practice Address - Zip Code:21788-1912
Practice Address - Country:US
Practice Address - Phone:301-271-3535
Practice Address - Fax:301-271-2650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
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
PACJ8326OtherRAILROAD
PA1382371OtherHIGHMARK BLUE SHIELD
MD401065501Medicaid
PAS1FDOtherGEISINGER
PA20013086OtherAMERIHEALTH MERCY
PA1520447OtherGATEWAY
MDKX10OtherCAREFIRST MD BCBS
PA1007721360131Medicaid
PA03256300OtherCAPITAL BLUE CROSS
PA132622OtherUNISON
MD401065501OtherMARYLAND MEDICAL ASSISTANCE
PA7185822OtherAETNA
PA800174OtherJOHN HOPKINS
PA1007721360131Medicaid
PA1382371OtherHIGHMARK BLUE SHIELD
PA1007721360131Medicaid