Provider Demographics
NPI:1952331662
Name:POMMERENKE, FORREST A (MD)
Entity Type:Individual
Prefix:
First Name:FORREST
Middle Name:A
Last Name:POMMERENKE
Suffix:
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:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-0547
Mailing Address - Country:US
Mailing Address - Phone:843-663-8013
Mailing Address - Fax:843-663-8166
Practice Address - Street 1:4220 CAROLINA EXCHANGE DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-4220
Practice Address - Country:US
Practice Address - Phone:843-663-8013
Practice Address - Fax:843-663-8166
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22630208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC226302Medicaid
SC226302Medicaid