Provider Demographics
NPI:1285967208
Name:BLOOMSBURG PHYSICIANS SERVICES
Entity type:Organization
Organization Name:BLOOMSBURG PHYSICIANS SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:REGIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CABONOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-387-2100
Mailing Address - Street 1:PO BOX 919
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-0919
Mailing Address - Country:US
Mailing Address - Phone:570-387-2100
Mailing Address - Fax:570-387-2327
Practice Address - Street 1:4469 RED ROCK RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:PA
Practice Address - Zip Code:17814-7606
Practice Address - Country:US
Practice Address - Phone:570-925-6424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-09
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001811559Medicaid
PA039145Medicare PIN