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Organization
NORTHERN LANCASTER COUNTY MEDICAL GROUP
Active
Organization
NORTHERN LANCASTER COUNTY MEDICAL GROUP
Active
Other names
Wellspan Family Medicine-Lake Street
Organization subpart
No
Provider details
NPI number
Authorized official
CHARLES DAVID NOLL DO (VICE PRESIDENT)
(717) 859-5161
Entity
Organization
Contact information
Practice address
136 A & B LAKE STREET, EPHRATA, PA 17522-2415
(717) 721-7718
(717) 721-7726
Mailing address
136 LAKE ST, EPHRATA, PA 17522-2415
(717) 721-7718
(717) 721-7726
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1013977730008
—
PA
01
—
1746343
BLUE SHIELD
PA
01
—
DD6938
RAILROAD MEDICARE
PA
Enumeration date
09/08/2006
Last updated
10/15/2015
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