Healthcare Provider Details

I. General information

NPI: 1265952998
Provider Name (Legal Business Name): WELLSPRING FAMILY MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2017
Last Update Date: 07/21/2022
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 N 4TH ST
OAKLAND MD
21550-1371
US

IV. Provider business mailing address

311 N 4TH ST
OAKLAND MD
21550-1371
US

V. Phone/Fax

Practice location:
  • Phone: 301-334-7855
  • Fax: 301-334-7828
Mailing address:
  • Phone: 301-334-7855
  • Fax: 301-334-7828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number05746
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12014
License Number StateMD

VIII. Authorized Official

Name: RAMONA THOMAS
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 301-501-5110