Basic Information
| Provider Information | |||||||||
| NPI: | 1609868017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POMERANCE | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | NOEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1801 GUNBARREL RD | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374213130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238586800 | ||||||||
| FaxNumber: | 4238551108 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 GUNBARREL RD | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374213130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238586800 | ||||||||
| FaxNumber: | 4238551108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 01/25/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD0000015600 | TN | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0393990001 | 01 | TN | DMERC GROUP NUMBER | OTHER | TN0101 | 01 | TN | JOHN DEERE PROVIDER NUMBE | OTHER | 3709593 | 01 | TN | MEDICARE GROUP NUMBER | OTHER | 3709593 | 05 | TN | MEDICAID | 4139738 | 01 | TN | AETNA PROVIDER NUMBER | OTHER | 3008472 | 01 | TN | MEDICARE | OTHER | 36857 | 01 | TN | BLUE CROSS PROVIDER NUMBE | OTHER | 0452389 | 01 | TN | CIGNA PROVIDER NUMBER | OTHER | 180029735 | 01 | TN | RAILRAOD MEDICARE | OTHER |