Provider Demographics
NPI:1184615759
Name:PAGSISIHAN, HERMOGENES (MD)
Entity type:Individual
Prefix:DR
First Name:HERMOGENES
Middle Name:
Last Name:PAGSISIHAN
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 1:100 PROFESSIONAL PARK
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3874
Mailing Address - Country:US
Mailing Address - Phone:770-834-3351
Mailing Address - Fax:770-830-1518
Practice Address - Street 1:100 PROFESSIONAL PARK
Practice Address - Street 2:SUITE 204
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3874
Practice Address - Country:US
Practice Address - Phone:770-834-3351
Practice Address - Fax:770-830-1518
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050666207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA866670OtherBLUE CROSS
GA000925361DMedicaid
GAH44982Medicare UPIN
GA08BBQZPMedicare ID - Type UnspecifiedMEDICARE