1508047606 NPI number — NORTHER LANCASTER COUNTY MEDICAL GROUP

Table of content: (NPI 1508047606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508047606 NPI number — NORTHER LANCASTER COUNTY MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHER 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:
1508047606
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5626 OBERLIN DR
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92121-1705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4131 OREGON PIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROWNSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17508-5083
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-859-1123
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HEINE
Authorized Official First Name:
KENNY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF OPERATIONS
Authorized Official Telephone Number:
858-625-2990

Provider Taxonomy Codes

  • Taxonomy code: 332900000X , with the licence number:  OS004463L , 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)





Copyright © 2007-2025 www.npivalidator.com