Provider Demographics
NPI:1992037501
Name:MARJA J SPROCK MD, PLLC
Entity Type:Organization
Organization Name:MARJA J SPROCK MD, PLLC
Other - Org Name:CENTRAL FLORIDA UROGYNECOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARJA
Authorized Official - Middle Name:JOHANNA
Authorized Official - Last Name:SPROCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-622-8377
Mailing Address - Street 1:1009 HARVIN WAY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3282
Mailing Address - Country:US
Mailing Address - Phone:321-622-8377
Mailing Address - Fax:321-622-8377
Practice Address - Street 1:1009 HARVIN WAY
Practice Address - Street 2:SUITE 110
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3282
Practice Address - Country:US
Practice Address - Phone:321-622-8377
Practice Address - Fax:321-622-8377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-06
Last Update Date:2010-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLG10000003345261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG46847Medicare UPIN