Provider Demographics
NPI:1295720100
Name:POMEROY, OLIVER HENRY (MD)
Entity type:Individual
Prefix:
First Name:OLIVER
Middle Name:HENRY
Last Name:POMEROY
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 1:75 FRANCIS ST
Mailing Address - Street 2:RADIOLOGY, BRIGHAM AND WOMEN'S HOSPITAL
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6110
Mailing Address - Country:US
Mailing Address - Phone:732-732-9801
Mailing Address - Fax:
Practice Address - Street 1:850 BOYLSTON ST
Practice Address - Street 2:RADIOLOGY, SUITE 5
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-2477
Practice Address - Country:US
Practice Address - Phone:617-732-9801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA776402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAF93328BWHT1OtherHARVARD PILGRIM HEALTH CA
MA3133834Medicaid
MA760081OtherTUFTS HEALTH CARE
MAJ30858OtherBLUE CROSS/BLUE SHIELD
MA3133834Medicaid
MAJ30858Medicare ID - Type Unspecified