1992037501 NPI number — MARJA J SPROCK MD, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992037501 NPI number — MARJA J SPROCK MD, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARJA J SPROCK MD, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CENTRAL FLORIDA UROGYNECOLOGY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992037501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1009 HARVIN WAY
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
ROCKLEDGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32955-3282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-622-8377
Provider Business Mailing Address Fax Number:
321-622-8377

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1009 HARVIN WAY
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
ROCKLEDGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32955-3282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-622-8377
Provider Business Practice Location Address Fax Number:
321-622-8377
Provider Enumeration Date:
02/06/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SPROCK
Authorized Official First Name:
MARJA
Authorized Official Middle Name:
JOHANNA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
321-622-8377

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  G10000003345 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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