1538107560 NPI number — NORTHERN LANCASTER COUNTY MEDICAL GROUP

Table of content: (NPI 1538107560)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538107560 NPI number — NORTHERN LANCASTER COUNTY MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN LANCASTER COUNTY MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
STATE STREE FAMILY PRACTICE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538107560
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 398
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROWNSTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17508-0398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-859-2038
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 S STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EPHRATA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17522-2410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-733-4559
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MALIZIA
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
Authorized Official Title or Position:
VP NLCMG
Authorized Official Telephone Number:
717-738-2280

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1013977730012 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50051253 . This is a "BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7090090 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: DD6938 . This is a "RR MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1746355 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1517100 . This is a "GATEWAY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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