Provider Demographics
NPI:1053340679
Name:GEORGE, SUE ELLEN (MD)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:ELLEN
Last Name:GEORGE
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 1:5978 BERRYHILL RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-4009
Mailing Address - Country:US
Mailing Address - Phone:850-626-6363
Mailing Address - Fax:850-626-1414
Practice Address - Street 1:5978 BERRYHILL RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-4009
Practice Address - Country:US
Practice Address - Phone:850-626-6363
Practice Address - Fax:850-626-1414
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74859207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254229300Medicaid
FLF37649Medicare UPIN
FL254229300Medicaid