Provider Demographics
NPI:1790815421
Name:SUSQUEHANNA VENTURES, INC.
Entity Type:Organization
Organization Name:SUSQUEHANNA VENTURES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:RADOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-677-1037
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 1:1201 GRAMPIAN BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1900
Practice Address - Country:US
Practice Address - Phone:570-326-8109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UPMC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
PAPP413352L3336C0004X, 3336L0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3956351OtherNCPDP
PA1007515570011Medicaid
PA0519900001Medicare ID - Type Unspecified