Provider Demographics
NPI:1578627626
Name:SUSQUEHANNA VALLEY FOOT AND ANKLE CENTER, INC
Entity Type:Organization
Organization Name:SUSQUEHANNA VALLEY FOOT AND ANKLE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARLA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:570-374-3668
Mailing Address - Street 1:3120 N OLD TRL STE A
Mailing Address - Street 2:
Mailing Address - City:SHAMOKIN DAM
Mailing Address - State:PA
Mailing Address - Zip Code:17876-9428
Mailing Address - Country:US
Mailing Address - Phone:570-374-3668
Mailing Address - Fax:570-374-7306
Practice Address - Street 1:3120 N OLD TRL STE A
Practice Address - Street 2:
Practice Address - City:SHAMOKIN DAM
Practice Address - State:PA
Practice Address - Zip Code:17876-9428
Practice Address - Country:US
Practice Address - Phone:570-374-3668
Practice Address - Fax:570-374-7306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004004L213ES0103X
PASC004206R213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015721370004Medicaid
PA0015896440005Medicaid
PA053998Medicare ID - Type UnspecifiedGROUP ID NUMBER
PAU62053Medicare UPIN
PA0015721370004Medicaid