Healthcare Provider Details

I. General information

NPI: 1619996733
Provider Name (Legal Business Name): SUSQUEHANNA PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 GRAMPIAN BLVD SUITE 1B
WILLIAMSPORT PA
17701-1900
US

IV. Provider business mailing address

1205 GRAMPIAN BLVD PO BOX 3127
WILLIAMSPORT PA
17701-1978
US

V. Phone/Fax

Practice location:
  • Phone: 570-320-7570
  • Fax: 570-320-7571
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

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