Healthcare Provider Details

I. General information

NPI: 1821018607
Provider Name (Legal Business Name): RAYMOND POMERLEAU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 W LYON ST
TALLAPOOSA GA
30176-1288
US

IV. Provider business mailing address

301 AMBULANCE DR
CARROLLTON GA
30117-3865
US

V. Phone/Fax

Practice location:
  • Phone: 770-824-2824
  • Fax: 770-824-2810
Mailing address:
  • Phone:
  • Fax: 770-836-9261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number024476
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: