Healthcare Provider Details

I. General information

NPI: 1619177490
Provider Name (Legal Business Name): NORTHERN LANCASTER COUNTY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 05/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3413 HARVEST DR
GORDONVILLE PA
17529-9586
US

IV. Provider business mailing address

4131 OREGON PIKE SUITE C
EPHRATA PA
17522-9550
US

V. Phone/Fax

Practice location:
  • Phone: 717-768-7141
  • Fax: 717-768-3528
Mailing address:
  • Phone: 717-859-5161
  • Fax: 717-859-5169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD007574E
License Number StatePA

VIII. Authorized Official

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