Healthcare Provider Details

I. General information

NPI: 1083677868
Provider Name (Legal Business Name): SUSQUEHANNA PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 11/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 HIGH STREET
WILLIAMSPORT PA
17701-3198
US

IV. Provider business mailing address

1201 GRAMPIAN BLVD
WILLIAMSPORT PA
17701-1900
US

V. Phone/Fax

Practice location:
  • Phone: 570-321-3580
  • Fax: 570-321-3581
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. MELISSA DAVIS
Title or Position: VP/COO
Credential:
Phone: 570-320-7696