Provider Demographics
NPI:1649720772
Name:POMERENE GASTROENTEROLOGY
Entity type:Organization
Organization Name:POMERENE GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSTUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-674-1584
Mailing Address - Street 1:981 WOOSTER RD
Mailing Address - Street 2:ATTN: MELISSA FIELITZ
Mailing Address - City:MILLERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44654-1536
Mailing Address - Country:US
Mailing Address - Phone:330-674-1584
Mailing Address - Fax:330-674-9314
Practice Address - Street 1:1261 WOOSTER RD STE 210
Practice Address - Street 2:
Practice Address - City:MILLERSBURG
Practice Address - State:OH
Practice Address - Zip Code:44654
Practice Address - Country:US
Practice Address - Phone:330-763-2018
Practice Address - Fax:330-763-2063
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALTH PROFESSIONALS OF HOLMES COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-13
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2801418Medicaid
OH2801418Medicaid