1750325189 NPI number — NORTHERN LANCASTER COUNTY MEDICAL GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750325189 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:
Provider Other Organization Name Type Code:
6
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:
1750325189
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4131 OREGON PIKE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
EPHRATA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17522-9550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-859-5161
Provider Business Mailing Address Fax Number:
717-859-5169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2320 ROTHSVILLE RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LITITZ
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17543-8215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-721-4800
Provider Business Practice Location Address Fax Number:
717-626-1613
Provider Enumeration Date:
06/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NOLL
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
SENIOR PRACTICE MANAGER
Authorized Official Telephone Number:
717-859-5161

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  193400000X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1746277 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1013977730011 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: DD6938 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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