Provider Demographics
NPI:1053973636
Name:SIDRA GERGES, MARINA
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:SIDRA GERGES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 W 9TH STREET
Mailing Address - Street 2:UNIT A
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546
Mailing Address - Country:US
Mailing Address - Phone:513-546-3224
Mailing Address - Fax:
Practice Address - Street 1:966 BARTLEY ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-2641
Practice Address - Country:US
Practice Address - Phone:812-996-5425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11020796A207Q00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine