Provider Demographics
NPI:1932194271
Name:SUSQUEHANNA VALLEY PROSTHETICS & ORTHOTICS INC
Entity Type:Organization
Organization Name:SUSQUEHANNA VALLEY PROSTHETICS & ORTHOTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CERTIFIED PROSTHETIST
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:DOMINICK
Authorized Official - Suffix:III
Authorized Official - Credentials:CP
Authorized Official - Phone:570-743-1414
Mailing Address - Street 1:PO BOX 243
Mailing Address - Street 2:
Mailing Address - City:SHAMOKIN DAM
Mailing Address - State:PA
Mailing Address - Zip Code:17876
Mailing Address - Country:US
Mailing Address - Phone:570-743-1414
Mailing Address - Fax:570-743-5215
Practice Address - Street 1:3120 N OLD TRAIL
Practice Address - Street 2:
Practice Address - City:SHAMOKIN DAM
Practice Address - State:PA
Practice Address - Zip Code:17876
Practice Address - Country:US
Practice Address - Phone:570-743-1414
Practice Address - Fax:570-743-5215
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUSQUEHANNA VALLEY PROSTHETICS & ORTHOTICS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-13
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
116173OtherHEALTH AMERICA
SU206824OtherBLUE SHIELD
PA2477665OtherAETNA
PA340622OtherHEALTH AMERICA
39HA76OtherKEYSTONE HEALTH PLAN
PASU206824OtherHIGHMARK BLUE SHIELD
PA0018173000003Medicaid
PA1511123OtherGATEWAY
PA28389OtherABP ADMINISTRATION
PA39HA76OtherCAPITAL BLUE CROSS
PA57492OtherGEISINGER HEALTH PLAN
PA57492OtherGEISINGER HEALTH PLAN