Provider Demographics
NPI:1548343593
Name:POOLE, JEREMY W (DO)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:W
Last Name:POOLE
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:951 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6161
Mailing Address - Country:US
Mailing Address - Phone:229-228-4130
Mailing Address - Fax:229-226-4690
Practice Address - Street 1:951 S BROAD ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6161
Practice Address - Country:US
Practice Address - Phone:229-228-4130
Practice Address - Fax:229-226-4690
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2010-03-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA033433207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA024957OtherBCBS PROVIDER NUMBER
GA11DO266342OtherCLIA LAB PROVIDER NUMBER
GA728528012CMedicaid
GAGRP1474OtherMEDICARE GROUP NUMBER
GA0001417567 10OtherUNITED HEALTHCARE
GA0001417567 10OtherUNITED HEALTHCARE
GA11DO266342OtherCLIA LAB PROVIDER NUMBER