Healthcare Provider Details

I. General information

NPI: 1770272668
Provider Name (Legal Business Name): SUSQUEHANNA OB-GYN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 UPPER CHESAPEAKE DR
BEL AIR MD
21014-4339
US

IV. Provider business mailing address

308 N UNION AVE
HAVRE DE GRACE MD
21078-2825
US

V. Phone/Fax

Practice location:
  • Phone: 443-643-4300
  • Fax:
Mailing address:
  • Phone: 410-939-3121
  • Fax: 410-939-8278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VICTORIA DODSON
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 443-398-0189