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  7. NPI Record 1134455967

SUSQUEHANNA HEALTH MEDICAL GROUP
Complete NPI Record 1134455967
Preventive Medicine - Occupational Medicine in Williamsport, PA

NPI Status: Active since October 29, 2009

Contact Information

1100 GRAMPIAN BLVD
WILLIAMSPORT, PA
ZIP 17701
Phone: (570) 320-7444
Fax: (570) 320-7445

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Table of Contents

  1. NPI
  2. Entity Type Code
  3. Employer Identification Number EIN
  4. Provider Organization Name Legal Business Name
  5. Provider Other Organization Name
  6. Provider Other Organization Name Type Code
  7. Provider First Line Business Mailing Address
  8. Provider Business Mailing Address City Name
  9. Provider Business Mailing Address State Name
  10. Provider Business Mailing Address Postal Code
  11. Provider Business Mailing Address Country Code If outside U S
  12. Provider First Line Business Practice Location Address
  13. Provider Business Practice Location Address City Name
  14. Provider Business Practice Location Address State Name
  15. Provider Business Practice Location Address Postal Code
  16. Provider Business Practice Location Address Country Code If outside U S
  17. Provider Business Practice Location Address Telephone Number
  18. Provider Business Practice Location Address Fax Number
  19. Provider Enumeration Date
  20. Last Update Date
  21. Authorized Official Last Name
  22. Authorized Official First Name
  23. Authorized Official Title or Position
  24. Authorized Official Telephone Number
  25. Healthcare Provider Taxonomy Code 1
  26. Healthcare Provider Primary Taxonomy Switch 1
  27. Healthcare Provider Taxonomy Code 2
  28. Healthcare Provider Primary Taxonomy Switch 2
  29. Other Provider Identifier 1
  30. Other Provider Identifier Type Code 1
  31. Other Provider Identifier State 1
  32. Is Organization Subpart
  33. Authorized Official Name Prefix Text
  34. Healthcare Provider Taxonomy Group 1
  35. Healthcare Provider Taxonomy Group 2

Complete NPI Dataset

This page represents the complete record for NPI 1134455967. You can access the complete dataset, including a full list of field names, along with their values, and definitions as recorded by the NPI registry. Each field in the NPI record is explained, highlighting its significance and the possible values it can hold.

NPI: 1134455967
The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
Entity Type Code: 2
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Employer Identification Number EIN: UNAVAIL
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
The name of the organization provider. If the provider is an organization, this is the legal business name.
Provider Other Organization Name: SUSQUEHANNA HEALTH MEDICAL GROUP
Other name by which the organization provider is or has been known.
Provider Other Organization Name Type Code: 3
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other.
Provider First Line Business Mailing Address: 1201 GRAMPIAN BLVD
The first line mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider first line location address’’.
Provider Business Mailing Address City Name: WILLIAMSPORT
The city name in the mailing address of the provider being identified.
Provider Business Mailing Address State Name: PA
The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address State name’’.
Provider Business Mailing Address Postal Code: 177011900
The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ‘‘Provider location address postal code’’.
Provider Business Mailing Address Country Code If outside U S : US
The country code in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address country code’’.
Provider First Line Business Practice Location Address: 1100 GRAMPIAN BLVD
The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City Name: WILLIAMSPORT
The city name in the location address of the provider being identified.
Provider Business Practice Location Address State Name: PA
The State code in the location of the provider being identified.
Provider Business Practice Location Address Postal Code: 177011909
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Country Code If outside U S : US
The country code in the location address of the provider being identified.
Provider Business Practice Location Address Telephone Number: 5703207444
The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address Fax Number: 5703207445
The fax number associated with the location address of the provider being identified.
Provider Enumeration Date: 10/29/2009
The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date: 10/27/2015
The date that a record was last updated or changed.
Authorized Official Last Name: DAVIS
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
Authorized Official First Name: MELISSA
The first name of the authorized official.
Authorized Official Title or Position: VP/COO
The title or position of the authorized official.
Authorized Official Telephone Number: 5703207696
The 10-position telephone number of the authorized official.
Healthcare Provider Taxonomy Code 1: 363A00000X
Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
Healthcare Provider Primary Taxonomy Switch 1: N
Healthcare Provider Taxonomy Code 2: 2083X0100X
Healthcare Provider Primary Taxonomy Switch 2: Y
Other Provider Identifier 1: 0017300760209
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 1: 05
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 1: PA
Is Organization Subpart: N
Authorized Official Name Prefix Text: MS.
Healthcare Provider Taxonomy Group 1: 193200000X MULTI-SPECIALTY GROUP
Healthcare Provider Taxonomy Group 2: 193200000X MULTI-SPECIALTY GROUP