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
1	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1578289302
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	:	341-888-7637
Fax Number	:

Provider Business Practice Location Address
First Line	:	13236 N 7TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85022-5343
Country	:	US
Telephone Number	:	341-888-7637
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	AMY HALANSKI
Credential	:
Telephone Number	:	341-888-7637

Provider Enumeration Date	:	10/13/2022
Last Update Date	:	10/13/2022

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