Provider Demographics
NPI:1306849625
Name:SUPRYS, MARIANNE J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIANNE
Middle Name:J
Last Name:SUPRYS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1012 WATER ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-3444
Mailing Address - Country:US
Mailing Address - Phone:814-336-5995
Mailing Address - Fax:814-333-1025
Practice Address - Street 1:210 N MERCER ST
Practice Address - Street 2:
Practice Address - City:LINESVILLE
Practice Address - State:PA
Practice Address - Zip Code:16424-9232
Practice Address - Country:US
Practice Address - Phone:814-683-2014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042437E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012040880004Medicaid
PA20047 FCNOtherEPSDT
PAE65436OtherHEALTH AMERICA
PA122811OtherUNISON HEALTH PLAN
PA205047OtherUPMC HEALTH PLAN
PA0012040880007Medicaid
PA080084839OtherPALMETTO GBA-RAILROAD MEDICARE
PA251754199019OtherMEDICAL MUTUAL OF OHIO
PA902560OtherHIGHMARK BLUE CROSS BLUE SHIELD
PA4235190002OtherNATIONAL SUPPLIERS CLEARINGHOUSE
PA4235190002OtherNATIONAL SUPPLIERS CLEARINGHOUSE
PA251754199019OtherMEDICAL MUTUAL OF OHIO