Healthcare Provider Details

I. General information

NPI: 1447224118
Provider Name (Legal Business Name): SAM S. BANG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 02/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 IRONSTONE DR
NORTHUMBERLAND PA
17857-8543
US

IV. Provider business mailing address

1 HOSPITAL DR SUITE 306
LEWISBURG PA
17837-9350
US

V. Phone/Fax

Practice location:
  • Phone: 570-473-0545
  • Fax: 570-473-7410
Mailing address:
  • Phone: 570-522-4110
  • Fax: 570-768-3911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS011866
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: