Provider Demographics
NPI:1346428174
Name:SUSQUEHANNA PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:SUSQUEHANNA PHYSICIAN SERVICES
Other - Org Name:SPS-INTERNAL MEDICINE WEST FOURTH ST
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE VP CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTANGELO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-321-3171
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:PO BOX 3127
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-0127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:699 RURAL AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3246
Practice Address - Country:US
Practice Address - Phone:570-321-3228
Practice Address - Fax:570-321-3238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2010019OtherHIGHMARK BLUE SHIELD
PA0017300760166Medicaid
PACC0890Medicare PIN
PA121547Medicare PIN