Provider Demographics
NPI:1427065457
Name:NORTHERN LANCASTER MEDICAL GROUP
Entity type:Organization
Organization Name:NORTHERN LANCASTER 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 1:4131 OREGON PIKE
Mailing Address - Street 2:SUITE C
Mailing Address - City:EPHRATA
Mailing Address - State:PA
Mailing Address - Zip Code:17522
Mailing Address - Country:US
Mailing Address - Phone:717-859-5171
Mailing Address - Fax:717-859-5169
Practice Address - Street 1:770 BROAD STREET
Practice Address - Street 2:
Practice Address - City:TERRE HILL
Practice Address - State:PA
Practice Address - Zip Code:17581-0130
Practice Address - Country:US
Practice Address - Phone:717-445-4576
Practice Address - Fax:717-445-4483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1746284OtherBLUE SHIELD
PADD6938OtherRAILROAD MEDICARE
PA1013977730002Medicaid
PA1013977730002Medicaid