Provider Demographics
NPI:1700805850
Name:SUSQUEHANNA PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:SUSQUEHANNA PHYSICIAN SERVICES
Other - Org Name:SPS-WAGNER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTANGELO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-321-3171
Mailing Address - Street 1:1205 GRAMPIAN BLVD
Mailing Address - Street 2:PO BOX 3127
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1978
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:531 BROAD ST
Practice Address - Street 2:
Practice Address - City:MONTOURSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17754-2338
Practice Address - Country:US
Practice Address - Phone:570-368-2235
Practice Address - Fax:570-368-3932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA880690OtherHIGHMARK BLUE SHIELD