Provider Demographics
NPI:1972529543
Name:FAMILY HEALTH CLINIC INC
Entity Type:Organization
Organization Name:FAMILY HEALTH CLINIC INC
Other - Org Name:SUSQUEHANNA FAMILY HEALTH CLINIC INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-853-3995
Mailing Address - Street 1:PO BOX 11
Mailing Address - Street 2:
Mailing Address - City:SUSQUEHANNA
Mailing Address - State:PA
Mailing Address - Zip Code:18847-0011
Mailing Address - Country:US
Mailing Address - Phone:570-853-3995
Mailing Address - Fax:570-853-3728
Practice Address - Street 1:401 BROAD AVE
Practice Address - Street 2:
Practice Address - City:SUSQUEHANNA
Practice Address - State:PA
Practice Address - Zip Code:18847-1611
Practice Address - Country:US
Practice Address - Phone:570-853-3995
Practice Address - Fax:570-853-3728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024723E261QH0100X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011996300001Medicaid
PA393843Medicare Oscar/Certification
PAC31153Medicare UPIN