# SUSQUEHANNA PHYSICIAN SERVICES

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Susquehanna Health Medical Group
- **Organization subpart:** No

## Provider details

- **NPI number:** 1992722524
- **Authorized official:** MS. MELISSA DAVIS (VP/COO)
- **Authorized official phone:** (570) 320-7696

## Contact information

- **Practice address:** 1100 GRAMPIAN BLVD, WILLIAMSPORT, PA 17701-1909
- **Practice address phone:** (570) 326-8550
- **Practice address fax:** (570) 326-8551
- **Mailing address:** 1201 GRAMPIAN BLVD, WILLIAMSPORT, PA 17701-1900

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2083P0011X | Undersea and Hyperbaric Medicine (Preventive Medicine) Physician | — | — | Yes |
| 2083P0901X | Public Health & General Preventive Medicine Physician | — | — | — |
| 2086S0129X | Vascular Surgery Physician | — | — | — |
| 213ES0103X | Foot & Ankle Surgery Podiatrist | — | — | — |

## Other

- **Enumeration date:** 07/17/2006
- **Last updated:** 09/28/2015

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 0017300760199 | — | PA |
| 01 | — | 1580634 | HIGHMARK BLUE SHIELD | PA |