MEDICARE: SALLY JO FERGUSON-AVERY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	MD423495	PA
2	207R00000X	Internal Medicine Physician	MD423495	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508805615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALLY JO FERGUSON-AVERY MD

Provider Business Mailing Address
First Line	:	7 DOCK HILL RD
Second Line	:
City	:	MIDDLEBURG
State	:	PA
Zip	:	17842-8910
Country	:	US
Telephone Number	:	570-837-2123
Fax Number	:	570-837-2185

Provider Business Practice Location Address
First Line	:	3057 N SUSQUEHANNA TRL
Second Line	:
City	:	SHAMOKIN DAM
State	:	PA
Zip	:	17876-9114
Country	:	US
Telephone Number	:	570-743-1112
Fax Number	:	570-743-1114

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	04/15/2022

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