# WELLSPAN MEDICAL GROUP

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- **Entity:** Organization
- **Status:** Active
- **Other names:** WellSpan Family Medicine - Lake Street
- **Organization subpart:** No

## Provider details

- **NPI number:** 1588114094
- **Authorized official:** CHRISTINA MOON (SUPERVISOR-VERIFICATION SERVICES)
- **Authorized official phone:** (717) 851-1405

## Contact information

- **Practice address:** 136 LAKE ST, EPHRATA, PA 17522-2415
- **Practice address phone:** (717) 721-7718
- **Practice address fax:** (717) 721-7726
- **Mailing address:** 3421 CONCORD RD, YORK, PA 17402-9001
- **Mailing address phone:** (717) 851-1405
- **Mailing address fax:** (717) 851-6969

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 10/07/2016
- **Last updated:** 10/07/2016