Healthcare Provider Details

I. General information

NPI: 1184286528
Provider Name (Legal Business Name): PAULINE SKOWRON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2019
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 VERNON RD
LAGRANGE GA
30240-3871
US

IV. Provider business mailing address

1805 VERNON RD
LAGRANGE GA
30240-3871
US

V. Phone/Fax

Practice location:
  • Phone: 67-884-2691
  • Fax: 706-845-7314
Mailing address:
  • Phone: 67-884-2691
  • Fax: 706-845-7314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number103713
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: