Healthcare Provider Details

I. General information

NPI: 1396970547
Provider Name (Legal Business Name): SUSQUEHANNA PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 06/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 GRAMPIAN BLVD SUITE 2E
WILLIAMSPORT PA
17701-1966
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 570-326-8502
  • Fax: 570-326-8049
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

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