Healthcare Provider Details

I. General information

NPI: 1992722524
Provider Name (Legal Business Name): SUSQUEHANNA PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 GRAMPIAN BLVD
WILLIAMSPORT PA
17701-1909
US

IV. Provider business mailing address

1201 GRAMPIAN BLVD
WILLIAMSPORT PA
17701-1900
US

V. Phone/Fax

Practice location:
  • Phone: 570-326-8550
  • Fax: 570-326-8551
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

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