Healthcare Provider Details

I. General information

NPI: 1750325189
Provider Name (Legal Business Name): NORTHERN LANCASTER COUNTY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 ROTHSVILLE RD SUITE 200
LITITZ PA
17543-8215
US

IV. Provider business mailing address

4131 OREGON PIKE SUITE C
EPHRATA PA
17522-9550
US

V. Phone/Fax

Practice location:
  • Phone: 717-721-4800
  • Fax: 717-626-1613
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 Number193400000X
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1746277
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE SHIELD
# 2
Identifier1013977730011
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 3
IdentifierDD6938
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name: CHARLES DAVID NOLL
Title or Position: SENIOR PRACTICE MANAGER
Credential: DO
Phone: 717-859-5161