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NPI Code Detail

MEDICARE: WELLNITE MEDICAL GROUP PA

MEDICARE: WELLNITE MEDICAL GROUP PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12084P0800XPsychiatry Physician

General Provider Information

NPI Number : 1053028928
Entity Type Code : Organization
Provider Name (Legal Business Name) : WELLNITE MEDICAL GROUP PA
Provider Business Mailing Address
First Line : 2261 MARKET ST # 4058
Second Line :
City : SAN FRANCISCO
State : CA
Zip : 94114-1612
Country : US
Telephone Number : 855-731-1410
Fax Number :
Provider Business Practice Location Address
First Line : 136 FORUM DR STE 4
Second Line :
City : COLUMBIA
State : SC
Zip : 29229-7980
Country : US
Telephone Number : 341-888-7637
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : AMY HALANSKI
Credential :
Telephone Number : 877-644-6008
Provider Enumeration Date : 11/01/2022
Last Update Date : 06/15/2023

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