Provider Demographics
NPI:1689857070
Name:BLOOMSBURG PHYSICIANS SERVICES
Entity Type:Organization
Organization Name:BLOOMSBURG PHYSICIANS SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEVITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-387-2148
Mailing Address - Street 1:549 FAIR ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-1419
Mailing Address - Country:US
Mailing Address - Phone:570-387-2100
Mailing Address - Fax:
Practice Address - Street 1:410 GLENN AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1200
Practice Address - Country:US
Practice Address - Phone:570-387-7676
Practice Address - Fax:570-387-7677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD421245207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1487886OtherHIGHMARK BLUE SHIELD