Provider Demographics
NPI:1104988740
Name:WELLSPAN MEDICAL GROUP
Entity type:Organization
Organization Name:WELLSPAN MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:SWEITZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-851-6838
Mailing Address - Street 1:601 MEMORY LN
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-2231
Mailing Address - Country:US
Mailing Address - Phone:717-851-1405
Mailing Address - Fax:717-851-1665
Practice Address - Street 1:30 MONUMENT ROAD
Practice Address - Street 2:SUITE 1100
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-5024
Practice Address - Country:US
Practice Address - Phone:717-851-6454
Practice Address - Fax:717-851-1665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD04P5OtherCAREFIRST MD BCBS-STE 190
PA1007721360105Medicaid
PA344TOtherGEISINGER
PA50039030OtherCAPITAL BLUE CROSS
PACA3246OtherRAILROAD MEDICARE
MDKC94OtherCAREFIRST BCBS
PA20034217OtherAMERIHEALTH MERCY
PA1536225OtherGATEWAY
PA2305610000OtherAMERIHEALTH 65PA
PA800174OtherJOHN HOPKINS
PA1628553OtherHIGHMARK BLUE SHIELD
PA=========OtherTRICARE BANNISTER ST
PA1007721360246Medicaid
MD401065514Medicaid
PA7619892OtherAETNA
PA=========OtherTRICARE WASHINGTON ST
MD401065514Medicaid