Provider Demographics
NPI:1124104245
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:717-851-3382
Practice Address - Street 1:1001 S GEORGE ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-3676
Practice Address - Country:US
Practice Address - Phone:717-851-3884
Practice Address - Fax:717-851-3382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7783839OtherAETNA
PAHIGHMARKOther1955304
PA03005900OtherCAPITAL BLUE CROSS
PA174862OtherUNISON HP
PA1548228OtherGATEWAY
PA800174OtherJOHN HOPKINS HP
PA68581007OtherAMERIHEALTH 65 PA
PAKX53OtherCAREFIRST MD BC/BS
PA20016312OtherAMERIHEALTH MERCY
PA1007721360260Medicaid
PA339TOtherGEISINGER
PACA3246OtherRAILROAD MEDICARE
PA339TOtherGEISINGER
PA117038FLTMedicare PIN