Provider Demographics
NPI:1346344561
Name:NORTHERN LANCASTER COUNTY MEDICAL GROUP
Entity Type:Organization
Organization Name:NORTHERN LANCASTER COUNTY MEDICAL GROUP
Other - Org Name:WELLSPAN FAMILY MEDICINE-LAKE STREET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:NOLL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:717-859-5161
Mailing Address - Street 1:136 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:PA
Mailing Address - Zip Code:17522-2415
Mailing Address - Country:US
Mailing Address - Phone:717-721-7718
Mailing Address - Fax:717-721-7726
Practice Address - Street 1:136 A & B LAKE STREET
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-2415
Practice Address - Country:US
Practice Address - Phone:717-721-7718
Practice Address - Fax:717-721-7726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADD6938OtherRAILROAD MEDICARE
PA1013977730008Medicaid
PA1746343OtherBLUE SHIELD
PA1746343OtherBLUE SHIELD