Provider Demographics
NPI:1184881393
Name:SALLY SUZANNE MARIE MD
Entity type:Organization
Organization Name:SALLY SUZANNE MARIE MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:MARIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-654-4175
Mailing Address - Street 1:1755 COBURG RD STE 5
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4982
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1755 COBURG RD STE 5
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4982
Practice Address - Country:US
Practice Address - Phone:541-654-4175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14482207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR142976Medicaid
ORC91440Medicare UPIN
OR100040Medicare PIN