Provider Demographics
NPI:1932155181
Name:NORTHERN LANCASTER COUNTY MEDICAL GROUP
Entity Type:Organization
Organization Name:NORTHERN LANCASTER COUNTY MEDICAL GROUP
Other - Org Name:WELLSPAN FAMILY MEDICINE - MEADOWBROOK
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:
Practice Address - Street 1:337 W MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LEOLA
Practice Address - State:PA
Practice Address - Zip Code:17540-2109
Practice Address - Country:US
Practice Address - Phone:717-656-6122
Practice Address - Fax:717-656-0142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1517089OtherGATEWAY
PA5372553OtherAETNA
PA1013977730018Medicaid
PA1746348OtherBLUE SHIELD
PA50051234OtherCAPITAL BLUE CROSS
PADD6938OtherRR MEDICARE
PADD6938OtherRR MEDICARE
PA5372553OtherAETNA