Healthcare Provider Details

I. General information

NPI: 1407873045
Provider Name (Legal Business Name): SUSQUEHANNA VALLEY MEDICAL SPECIALTIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 10/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6850 LOWS RD
BLOOMSBURG PA
17815-8729
US

IV. Provider business mailing address

6850 LOWS RD
BLOOMSBURG PA
17815-8729
US

V. Phone/Fax

Practice location:
  • Phone: 570-784-7300
  • Fax: 570-784-7331
Mailing address:
  • Phone: 570-784-7300
  • Fax: 570-784-7331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StatePA

VIII. Authorized Official

Name: MARK S WILLIAMS
Title or Position: PRESIDENT
Credential: DO
Phone: 570-784-7300