Healthcare Provider Details

I. General information

NPI: 1801830807
Provider Name (Legal Business Name): SUSQUEHANNA PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 WARREN AVE SUITE 101-103
WILLIAMSPORT PA
17701-2647
US

IV. Provider business mailing address

1201 GRAMPIAN BLVD
WILLIAMSPORT PA
17701-1900
US

V. Phone/Fax

Practice location:
  • Phone: 570-321-2020
  • Fax: 570-320-7501
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State

VIII. Authorized Official

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