Organization
SUSQUEHANNA PHYSICIAN SERVICES
Active
Other names
SPS-Loyalsock Pediatrics
Organization subpart
No
Provider details
NPI number
Authorized official
MR. CHARLES SANTANGELO (EXECUTIVE VP/CFO)
(570) 321-3171
Entity
Organization
Contact information
Practice address
904 CAMPBELL ST, WILLIAMSPORT, PA 17701-3166
(570) 321-3100
(570) 321-3101
Mailing address
1201 GRAMPIAN BLVD, PO BOX 3127, WILLIAMSPORT, PA 17701-0127
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
—
—
363A00000X
Physician Assistant
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0017300760190
—
PA
01
—
714360
HIGHMARK BLUE SHIELD
PA
Enumeration date
06/30/2006
Last updated
05/26/2010
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