Provider Demographics
NPI:1003176546
Name:MISTY D. POOLE, MD, LLC
Entity Type:Organization
Organization Name:MISTY D. POOLE, MD, LLC
Other - Org Name:VIDALIA INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:D
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-537-2200
Mailing Address - Street 1:210 MOSE COLEMAN DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8677
Mailing Address - Country:US
Mailing Address - Phone:912-537-2200
Mailing Address - Fax:912-537-2260
Practice Address - Street 1:210 MOSE COLEMAN DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8677
Practice Address - Country:US
Practice Address - Phone:912-537-2200
Practice Address - Fax:912-537-2260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-17
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2021111317OtherMEDICARE