Provider Demographics
NPI:1184888778
Name:NORTHERN LANCASTER COUNTY MEDICAL GROUP
Entity type:Organization
Organization Name:NORTHERN LANCASTER COUNTY MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:264 GRANITE RUN DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-6804
Mailing Address - Country:US
Mailing Address - Phone:717-721-8205
Mailing Address - Fax:717-721-8251
Practice Address - Street 1:264 GRANITE RUN DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-6804
Practice Address - Country:US
Practice Address - Phone:717-721-8205
Practice Address - Fax:717-721-8251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-14
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD032838L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013977730021Medicaid
092914Medicare PIN