Provider Demographics
NPI:1861495491
Name:STROM, PRISCILLA RUTH (MD)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:RUTH
Last Name:STROM
Suffix:
Gender:F
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:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-535-7445
Practice Address - Street 1:725 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3834
Practice Address - Country:US
Practice Address - Phone:770-536-2323
Practice Address - Fax:770-536-4947
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021053208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52476028OtherBCBS
GA000221955JMedicaid
GA343257OtherWELLCARE
GA1415794OtherCIGNA
GA000221955HMedicaid
GA01050059OtherAMERIGROUP
GAP00434214OtherMEDICARE RAILROAD
GA000221955HOtherPEACH STATE
GA1177000OtherUHC
GA5151005OtherAETNA
GA572604OtherCOVENTRY
GA52476028OtherBCBS
GA1177000OtherUHC