Provider Demographics
NPI:1619972486
Name:GEORGESON, PAMELA A (DO)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:A
Last Name:GEORGESON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30170 23 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-2190
Mailing Address - Country:US
Mailing Address - Phone:586-949-5900
Mailing Address - Fax:586-949-5922
Practice Address - Street 1:30170 23 MILE RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-2190
Practice Address - Country:US
Practice Address - Phone:586-949-5900
Practice Address - Fax:586-949-5922
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2007-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008579207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4326232OtherAETNA
MI5500466OtherBCBSM
MIC2983OtherMCARE
MIPG008579OtherBCBSM OTHER IDENTIFIER
MI4326232OtherAETNA
MIC2983OtherMCARE