Provider Demographics
NPI:1295190809
Name:SUGRUE, MARJORIE
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:SUGRUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CALLE VERDE DR
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-6436
Mailing Address - Country:US
Mailing Address - Phone:478-365-1060
Mailing Address - Fax:
Practice Address - Street 1:105 CALLE VERDE DR
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-6436
Practice Address - Country:US
Practice Address - Phone:478-365-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-24
Last Update Date:2015-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20611207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine