MEDICARE: SUSQUEHANNA VALLEY FOOT AND ANKLE CENTER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	SC004206R	PA
2	213ES0103X	Foot & Ankle Surgery Podiatrist	SC004004L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578627626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUSQUEHANNA VALLEY FOOT AND ANKLE CENTER, INC

Provider Business Mailing Address
First Line	:	3120 N OLD TRL STE A
Second Line	:
City	:	SHAMOKIN DAM
State	:	PA
Zip	:	17876-9428
Country	:	US
Telephone Number	:	570-374-3668
Fax Number	:	570-374-7306

Provider Business Practice Location Address
First Line	:	3120 N OLD TRL STE A
Second Line	:
City	:	SHAMOKIN DAM
State	:	PA
Zip	:	17876-9428
Country	:	US
Telephone Number	:	570-374-3668
Fax Number	:	570-374-7306

Authorized Official
Title or Position	:	PHYSICIAN, PRESIDENT
Name	:	DARLA R MILLER
Credential	:	DPM
Telephone Number	:	570-374-3668

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	05/26/2023

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Directions to “SUSQUEHANNA VALLEY FOOT AND ANKLE CENTER, INC ” Practice Location

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