Provider Demographics
NPI:1235121658
Name:PUMPELLY, ROBERT ALLEN IV (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ALLEN
Last Name:PUMPELLY
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 IVY ST
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31546-3647
Mailing Address - Country:US
Mailing Address - Phone:912-427-7182
Mailing Address - Fax:912-530-6348
Practice Address - Street 1:124 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0101
Practice Address - Country:US
Practice Address - Phone:912-427-4413
Practice Address - Fax:912-530-6348
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022461207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300024546Medicaid
GA000066789MMedicaid
GA027470OtherBLUE CROSS BLUE SHIELD
GAD30528Medicare UPIN
GA027470OtherBLUE CROSS BLUE SHIELD
GACH9108Medicare ID - Type UnspecifiedRAILROAD GROUP NUMBER
GA000066789MMedicaid