Provider Demographics
NPI:1992037501
Name:MARJA J SPROCK MD, PLLC
Entity type:Organization
Organization Name:MARJA J SPROCK MD, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRISTAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KATTENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-338-2726
Mailing Address - Street 1:101 EYSTER BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3608
Mailing Address - Country:US
Mailing Address - Phone:321-806-3929
Mailing Address - Fax:321-806-3928
Practice Address - Street 1:101 EYSTER BLVD
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3608
Practice Address - Country:US
Practice Address - Phone:321-806-3929
Practice Address - Fax:321-809-3923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-06
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207VF0040X
FLG10000003345261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG46847Medicare UPIN