Provider Demographics
NPI:1366470973
Name:SUSQUEHANNA PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:SUSQUEHANNA PHYSICIAN SERVICES
Other - Org Name:SPS-LOYALSOCK PEDIATRICS
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 1:904 CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3166
Practice Address - Country:US
Practice Address - Phone:570-321-3100
Practice Address - Fax:570-321-3101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA714360OtherHIGHMARK BLUE SHIELD
PA0017300760190Medicaid