=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538107560
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN LANCASTER COUNTY MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2006
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 S STATE ST
-----------------------------------------------------
City | EPHRATA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17522-2410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-733-4559
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 398
-----------------------------------------------------
City | BROWNSTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17508-0398
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-859-2038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP NLCMG
-----------------------------------------------------
Name | CYNTHIA MALIZIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 717-738-2280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------