MEDICARE: PAMELA A GEORGESON DO

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	207K00000X	Allergy & Immunology Physician	5101008579	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4326232	OTHER	MI	AETNA
2	5500466	OTHER	MI	BCBSM
3	C2983	OTHER	MI	MCARE
4	PG008579	OTHER	MI	BCBSM OTHER IDENTIFIER

General Provider Information

NPI Number	:	1619972486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAMELA A GEORGESON DO

Provider Business Mailing Address
First Line	:	30170 23 MILE RD
Second Line	:
City	:	CHESTERFIELD
State	:	MI
Zip	:	48047-2190
Country	:	US
Telephone Number	:	586-949-5900
Fax Number	:	586-949-5922

Provider Business Practice Location Address
First Line	:	30170 23 MILE RD
Second Line	:
City	:	CHESTERFIELD
State	:	MI
Zip	:	48047-2190
Country	:	US
Telephone Number	:	586-949-5900
Fax Number	:	586-949-5922

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

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	07/14/2007

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