Healthcare Provider Details

I. General information

NPI: 1760414874
Provider Name (Legal Business Name): SUSQUEHANNA PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 05/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 CAMPBELL ST
WILLIAMSPORT PA
17701-3166
US

IV. Provider business mailing address

1201 GRAMPIAN BLVD PO BOX 3127
WILLIAMSPORT PA
17701-0127
US

V. Phone/Fax

Practice location:
  • Phone: 570-321-3110
  • Fax: 570-321-3114
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES SANTANGELO
Title or Position: EXECUTIVE VP/CFO
Credential:
Phone: 570-321-3171