Basic Information
| Provider Information | |||||||||
| NPI: | 1780631226 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUSQUEHANNA PHYSICIAN SERVICES | ||||||||
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| OtherOrganizationName: | SUSQUEHANNA HEALTH MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 GRAMPIAN BLVD | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177011900 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 145 SHAFFER ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177026727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703262447 | ||||||||
| FaxNumber: | 5703261247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 10/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP/COO | ||||||||
| AuthorizedOfficialTelephone: | 5703207696 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 888650 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 0017300760153 | 05 | PA | MEDICAID |