Provider Demographics
NPI:1780016253
Name:NORTHERN LANCASTER COUNTY MEDICAL GROUP
Entity Type:Organization
Organization Name:NORTHERN LANCASTER COUNTY MEDICAL GROUP
Other - Org Name:WELLSPAN FAMILY HEALTH - GEORGETOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
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 1:4131 OREGON PIKE
Mailing Address - Street 2:SUITE C
Mailing Address - City:EPHRATA
Mailing Address - State:PA
Mailing Address - Zip Code:17522-9550
Mailing Address - Country:US
Mailing Address - Phone:717-859-5161
Mailing Address - Fax:717-859-5169
Practice Address - Street 1:1135 GEORGETOWN ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:CHRISTIANA
Practice Address - State:PA
Practice Address - Zip Code:17509
Practice Address - Country:US
Practice Address - Phone:717-806-3800
Practice Address - Fax:717-806-3799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-06
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD053840L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013977730029Medicaid
PAG11497Medicare UPIN
PA1013977730029Medicaid