Provider Demographics
NPI:1588899736
Name:SUSQUEHANNA PHYSICIAN SERVICES
Entity type:Organization
Organization Name:SUSQUEHANNA PHYSICIAN SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VP/CFO
Authorized Official - Prefix:MR
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 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:PO BOX 3127
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-0127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 SHAFFER ST
Practice Address - Street 2:
Practice Address - City:SOUTH WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17702-6799
Practice Address - Country:US
Practice Address - Phone:570-326-2447
Practice Address - Fax:570-326-1247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017300760169Medicaid