Provider Demographics
NPI:1508805615
Name:FERGUSON-AVERY, SALLY JO (MD)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:JO
Last Name:FERGUSON-AVERY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:JO
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:3057 N SUSQUEHANNA TRL
Practice Address - Street 2:
Practice Address - City:SHAMOKIN DAM
Practice Address - State:PA
Practice Address - Zip Code:17876-9114
Practice Address - Country:US
Practice Address - Phone:570-743-1112
Practice Address - Fax:570-743-1114
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD423495208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1009301640002Medicaid
PA1009301640002Medicaid