Provider Demographics
NPI:1376758581
Name:POOLER PARKWAY INTERNAL MEDICINE, LLC
Entity Type:Organization
Organization Name:POOLER PARKWAY INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-330-5143
Mailing Address - Street 1:143 CANAL ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-6007
Mailing Address - Country:US
Mailing Address - Phone:912-330-5149
Mailing Address - Fax:
Practice Address - Street 1:143 CANAL ST
Practice Address - Street 2:SUITE 100
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-6007
Practice Address - Country:US
Practice Address - Phone:912-330-5149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA39698207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1932129822OtherMICHELLE L. WILSON, DO
GA1932129822OtherMICHELLE L. WILSON, DO