Provider Demographics
NPI:1720442718
Name:POMMERENKE, ALIX (MD)
Entity Type:Individual
Prefix:
First Name:ALIX
Middle Name:
Last Name:POMMERENKE
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 1:506 E CHEVES ST STE 202
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2616
Mailing Address - Country:US
Mailing Address - Phone:843-777-7000
Mailing Address - Fax:843-777-7005
Practice Address - Street 1:506 E CHEVES ST STE 202
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2616
Practice Address - Country:US
Practice Address - Phone:843-777-7000
Practice Address - Fax:843-777-7005
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-06
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD84012207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC840120Medicaid