Provider Demographics
NPI:1275500050
Name:MARIE, SALLY SUZANNE (MD)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:SUZANNE
Last Name:MARIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 COBURG RD STE 5
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4982
Mailing Address - Country:US
Mailing Address - Phone:541-654-4175
Mailing Address - Fax:541-844-1291
Practice Address - Street 1:1755 COBURG RD STE 5
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4982
Practice Address - Country:US
Practice Address - Phone:541-654-4175
Practice Address - Fax:541-844-1291
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14482207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR142976Medicaid
OR142976Medicaid
ORR141679Medicare PIN