Healthcare Provider Details

I. General information

NPI: 1346344561
Provider Name (Legal Business Name): NORTHERN LANCASTER COUNTY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 10/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 A & B LAKE STREET
EPHRATA PA
17522-2415
US

IV. Provider business mailing address

136 LAKE ST
EPHRATA PA
17522-2415
US

V. Phone/Fax

Practice location:
  • Phone: 717-721-7718
  • Fax: 717-721-7726
Mailing address:
  • Phone: 717-721-7718
  • Fax: 717-721-7726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES DAVID NOLL
Title or Position: VICE PRESIDENT
Credential: DO
Phone: 717-859-5161