Basic Information
| Provider Information | |||||||||
| NPI: | 1932176104 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL SUSQUEHANNA SURGICAL SPECIALISTS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 135 JPM RD | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705233290 | ||||||||
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| Practice Location | |||||||||
| Address1: | 135 JPM RD | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705233290 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DEITER | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5705233290 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0010499910007 | 05 | PA | MEDICAID |