1619177490 NPI number — NORTHERN LANCASTER COUNTY MEDICAL GROUP

Table of content: (NPI 1619177490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619177490 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:
1619177490
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2015
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:
3413 HARVEST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GORDONVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17529-9586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-768-7141
Provider Business Practice Location Address Fax Number:
717-768-3528
Provider Enumeration Date:
07/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NOLL
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
717-859-5161

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD007574E , 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: 1013977730025 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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