Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 N OLD TRL STE A
SHAMOKIN DAM PA
17876-9428
US

IV. Provider business mailing address

3120 N OLD TRL STE A
SHAMOKIN DAM PA
17876-9428
US

V. Phone/Fax

Practice location:
  • Phone: 570-374-3668
  • Fax: 570-374-7306
Mailing address:
  • Phone: 570-374-3668
  • Fax: 570-374-7306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC004206R
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC004004L
License Number StatePA

VIII. Authorized Official

Name: DARLA R MILLER
Title or Position: PHYSICIAN, PRESIDENT
Credential: DPM
Phone: 570-374-3668