MEDICARE: DR. SAGE VERMONT THURLBY M.D.

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	207Q00000X	Family Medicine Physician	L6199	TX
2	207Q00000X	Family Medicine Physician	E4410	AR

General Provider Information

NPI Number	:	1770520900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAGE VERMONT THURLBY M.D.

Provider Business Mailing Address
First Line	:	135 ALABAMA DR
Second Line	:
City	:	JACKSONVILLE
State	:	AR
Zip	:	72076-1003
Country	:	US
Telephone Number	:	501-920-7309
Fax Number	:	501-533-3029

Provider Business Practice Location Address
First Line	:	1480 W 1ST ST N
Second Line	:
City	:	PRESCOTT
State	:	AR
Zip	:	71857-3339
Country	:	US
Telephone Number	:	870-887-2669
Fax Number	:	870-887-5373

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

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	05/11/2011

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