Provider Demographics
NPI:1538114921
Name:EBRON, MARIAN T (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARIAN
Middle Name:T
Last Name:EBRON
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 1:2047 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-4178
Mailing Address - Country:US
Mailing Address - Phone:706-738-7557
Mailing Address - Fax:706-738-7526
Practice Address - Street 1:2047 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-4178
Practice Address - Country:US
Practice Address - Phone:706-738-7557
Practice Address - Fax:706-738-7526
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041783207Q00000X, 208D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000709684BMedicaid
GA52678333 003OtherBCBSGA
GA11BDSFDMedicare PIN
GA52678333 003OtherBCBSGA