NPIMap

Organization Active NPI

Susquehanna Physician Services

  • Psychiatry Physician
  • Williamsport, PA
National Provider Identifier
1831132927
Registry record updated Dec 4, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
SUSQUEHANNA PHYSICIAN SERVICES
Practice address
1100 Grampian Blvd
Williamsport, PA 17701-1909
Phone
(570) 320-7525
Fax
(570) 320-7484
NPI assigned
Jun 14, 2006
Last updated
Dec 4, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 4, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Melissa Davis
Title
VP/Coo
Phone
(570) 320-7696

Specialties & licenses 7

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X NU
Professional Counselor 101YP2500X PA
Psychologist 103T00000X NU
Clinical Psychologist 103TC0700X NU
Clinical Social Worker 1041C0700X NU
Marriage & Family Therapist 106H00000X NU
Psychiatry Physician 2084P0800X NU Primary

Addresses

Primary practice location

1100 Grampian Blvd
Williamsport, PA 17701-1909

Mailing address

1201 Grampian Blvd
Williamsport, PA 17701-1900

Other identifiers 2

IdentifierTypeStateIssuer
0017300760154MedicaidPA
424132OtherPAHIGHMARK BLUE SHIELD

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040503000889 PA Part B Supplier - Clinic/Group Practice 2264336460 Receives reassigned benefits from 24 practitioners
Practice locations: Williamsport, PA

National Provider Directory

National Provider Directory

Locations

1100 Grampian Blvd
Fl 5
Williamsport, PA 17701
Phone (570) 320-7525

1201 Grampian Blvd
Williamsport, PA 17701
Phone (570) 326-8723

Practitioners & affiliated clinicians

Practitioners 28

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 28

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150243200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1512345600000",
    "number": "1831132927",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1201 GRAMPIAN BLVD",
            "city": "WILLIAMSPORT",
            "state": "PA",
            "postal_code": "177011900"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1100 GRAMPIAN BLVD",
            "city": "WILLIAMSPORT",
            "state": "PA",
            "postal_code": "177011909",
            "telephone_number": "570-320-7525",
            "fax_number": "570-320-7484"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SUSQUEHANNA PHYSICIAN SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-14",
        "last_updated": "2017-12-04",
        "status": "A",
        "authorized_official_last_name": "DAVIS",
        "authorized_official_first_name": "MELISSA",
        "authorized_official_title_or_position": "VP/COO",
        "authorized_official_telephone_number": "570-320-7696",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "PA",
            "license": null,
            "primary": false
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "106H00000X",
            "taxonomy_group": "",
            "desc": "Marriage & Family Therapist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0017300760154",
            "state": "PA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HIGHMARK BLUE SHIELD",
            "identifier": "424132",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Williamsport, PA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 4, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.