Healthcare Provider Details

I. General information

NPI: 1003229626
Provider Name (Legal Business Name): WELLSPAN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 01/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 SOFIA DR STE 208
SHREWSBURY PA
17361-5201
US

IV. Provider business mailing address

3421 CONCORD RD
YORK PA
17402-9001
US

V. Phone/Fax

Practice location:
  • Phone: 717-812-2400
  • Fax: 717-812-3005
Mailing address:
  • Phone: 717-812-7278
  • Fax: 717-812-7280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. CHRISTINA VEST
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 717-851-1405