Provider Demographics
NPI:1780631226
Name:SUSQUEHANNA PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:SUSQUEHANNA PHYSICIAN SERVICES
Other - Org Name:SUSQUEHANNA HEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/COO
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-320-7696
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 SHAFFER ST
Practice Address - Street 2:
Practice Address - City:SOUTH WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17702-6727
Practice Address - Country:US
Practice Address - Phone:570-326-2447
Practice Address - Fax:570-326-1247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA888650OtherHIGHMARK BLUE SHIELD
PA0017300760153Medicaid
PA0017300760153Medicaid
PA888650OtherHIGHMARK BLUE SHIELD