Provider Demographics
NPI:1538107560
Name:NORTHERN LANCASTER COUNTY MEDICAL GROUP
Entity Type:Organization
Organization Name:NORTHERN LANCASTER COUNTY MEDICAL GROUP
Other - Org Name:STATE STREE FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP NLCMG
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALIZIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-738-2280
Mailing Address - Street 1:PO BOX 398
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17508-0398
Mailing Address - Country:US
Mailing Address - Phone:717-859-2038
Mailing Address - Fax:
Practice Address - Street 1:11 S STATE ST
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-2410
Practice Address - Country:US
Practice Address - Phone:717-733-4559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013977730012Medicaid
PA50051253OtherBLUE CROSS
PA7090090OtherAETNA
PADD6938OtherRR MEDICARE
PA1746355OtherBLUE SHIELD
PA1517100OtherGATEWAY
PA1013977730012Medicaid
PA1013977730012Medicaid