Provider Demographics
NPI:1770790974
Name:BLOOMSBURG PHYSICIAN SERVICES
Entity type:Organization
Organization Name:BLOOMSBURG PHYSICIAN SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-387-2148
Mailing Address - Street 1:410 GLENN AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-1200
Mailing Address - Country:US
Mailing Address - Phone:570-387-2339
Mailing Address - Fax:570-387-2487
Practice Address - Street 1:410 GLENN AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1200
Practice Address - Country:US
Practice Address - Phone:570-387-2339
Practice Address - Fax:570-387-2487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50052731OtherCBC NUMBER
PA0014107290004Medicaid
PA739865OtherHIGHMARK NUMBER
PA8807OtherGHP NUMBER
PA8807OtherGHP NUMBER
PA0014107290004Medicaid