Basic Information
| Provider Information | |||||||||
| NPI: | 1275601676 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPAN MEDICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WELLSPAN FAMILY MEDICINE - HERR'S RIDGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1803 MOUNT ROSE AVE | ||||||||
| Address2: | SUITE B3 | ||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174033051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | 7173374411 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 CHAMBERSBURG RD | ||||||||
| Address2: | |||||||||
| City: | GETTYSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173253310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7173374410 | ||||||||
| FaxNumber: | 7173374411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 01/11/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VEST | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7178511405 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1520445 | 01 | PA | GATEWAY | OTHER | 7865863 | 01 | PA | AETNA | OTHER | CA3246 | 01 | PA | RAILROAD MEDICARE | OTHER | 800174 | 01 | PA | JOHN HOPKINS | OTHER | KX10 | 01 | MD | CAREFIRST MD BCBS | OTHER | S1FB | 01 | PA | GEISINGER | OTHER | 03273300 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 130452 | 01 | PA | UNISON | OTHER | 20013070 | 01 | PA | AMERIHEALTH MERCY | OTHER | 0404995001 | 01 | PA | AMERIHEALTH 65 PA | OTHER | 1382344 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 401065502 | 01 | MD | MD MEDICAL ASSISTANCE | OTHER | 1007721360127 | 05 | PA | MEDICAID |