Provider Demographics
NPI:1164754602
Name:T R SUGGS MD MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:T R SUGGS MD MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THELBERT
Authorized Official - Middle Name:R
Authorized Official - Last Name:SUGGS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-698-1221
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32112-0098
Mailing Address - Country:US
Mailing Address - Phone:386-698-1221
Mailing Address - Fax:386-698-1514
Practice Address - Street 1:300 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:FL
Practice Address - Zip Code:32112-2729
Practice Address - Country:US
Practice Address - Phone:386-698-1221
Practice Address - Fax:386-698-1514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-09
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045328500Medicaid
FL012686688OtherRAILROAD MEDICARE
FL54029Medicare PIN
FLD86038Medicare UPIN