Provider Demographics
NPI:1053399253
Name:SUSQUEHANNA VALLEY PAIN MANAGEMENT PC
Entity type:Organization
Organization Name:SUSQUEHANNA VALLEY PAIN MANAGEMENT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MALIK
Authorized Official - Middle Name:N
Authorized Official - Last Name:MOMIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-652-8670
Mailing Address - Street 1:825 SIR THOMAS CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109
Mailing Address - Country:US
Mailing Address - Phone:717-652-8670
Mailing Address - Fax:717-901-5009
Practice Address - Street 1:825 SIR THOMAS CT
Practice Address - Street 2:SUITE B
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109
Practice Address - Country:US
Practice Address - Phone:717-652-8670
Practice Address - Fax:717-901-5009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA018860300004Medicaid
PA018860300004Medicaid