| Wellspring Family Medicine, Pc | |
|
311 N 4th St Suite 1 Oakland MD 21550-1395 | |
| (301) 334-7855 | |
| (301) 334-7828 |
| Full Name | Wellspring Family Medicine, Pc |
|---|---|
| Speciality | Family Medicine |
| Location | 311 N 4th St, Oakland, Maryland |
| Authorized Official Name and Position | Kenneth Robert Buczynski (PRESIDENT/PROVIDER) |
| Authorized Official Contact | 3013347855 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Wellspring Family Medicine, Pc 311 N 4th St Suite 1 Oakland MD 21550-1395 Ph: (301) 334-7855 | Wellspring Family Medicine, Pc 311 N 4th St Suite 1 Oakland MD 21550-1395 Ph: (301) 334-7855 |
| NPI Number | 1194744359 |
|---|---|
| Provider Enumeration Date | 07/19/2006 |
| Last Update Date | 01/24/2012 |
| Medicare PECOS PAC ID | 7012986763 |
|---|---|
| Medicare Enrollment ID | O20040929000439 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1194744359 | NPI | - | NPPES |
| 3810001034 | Medicaid | WV | |
| 64303201 | Other | MD | BCBS MD |
| K076-0001 | Other | MD | BCBS DC |
| 001663200 | Medicaid | MD | |
| 610547800 | Other | MD | FEDERAL BLACK LUNG # |
| 002509760 | Medicaid | MD | |
| 2128112 | Other | MD | MAMSI,ALL,OPT CH,MDIPA |
| Provider Name | Mark T Domenick |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1770536476 PECOS PAC ID: 4981687753 Enrollment ID: I20040611000615 |
| Provider Name | Kenneth R Buczynski |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1790704914 PECOS PAC ID: 1254300916 Enrollment ID: I20040930000045 |
| Provider Name | Richard A Porter |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1184646341 PECOS PAC ID: 0648230052 Enrollment ID: I20060926000260 |
| Provider Name | Stephanie Brook Sisler |
|---|---|
| Provider Type | Practitioner - Pediatric Medicine |
| Provider Identifiers | NPI Number: 1982963575 PECOS PAC ID: 3779886627 Enrollment ID: I20160127000156 |
| Provider Name | Lisa J Ryan |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1477911428 PECOS PAC ID: 9436458304 Enrollment ID: I20160917000357 |
| Provider Name | Marlana S Bollinger |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1093196826 PECOS PAC ID: 8022322114 Enrollment ID: I20181001000646 |
| Provider Name | Jason B Van Antwerp |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1811379563 PECOS PAC ID: 6103130281 Enrollment ID: I20190104001818 |
| Provider Name | Thomas M George |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1417338930 PECOS PAC ID: 7517299720 Enrollment ID: I20191021002145 |
| Provider Name | Stephen A Schaeffer |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1730618430 PECOS PAC ID: 0941571285 Enrollment ID: I20210216002731 |
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