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General NPI Number Information
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NPI Number | 1760414874
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Entity Type | Organization
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Legal Business Name | SUSQUEHANNA PHYSICIAN SERVICES
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Dates
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Enumeration Date | 07/07/2006
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Last Update Date | 05/20/2010
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Provider Practice Location Address
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Address Line | 904 CAMPBELL ST
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City | WILLIAMSPORT
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State | PA
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Zip | 17701-3166
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Country | US
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Telephone | 570-321-3110
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Fax | 570-321-3114
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Provider Business Mailing Address
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Address Line | 1201 GRAMPIAN BLVD PO BOX 3127
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City | WILLIAMSPORT
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State | PA
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Zip | 17701-0127
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE VP/CFO
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Name | MR. CHARLES SANTANGELO
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Credential |
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Telephone | 570-321-3171
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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