Provider Demographics
NPI:1992703193
Name:BROMER, RICHARD HARRIS (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:HARRIS
Last Name:BROMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3696 WHEELER ROAD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909
Mailing Address - Country:US
Mailing Address - Phone:706-736-1830
Mailing Address - Fax:706-736-4521
Practice Address - Street 1:3696 WHEELER RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6520
Practice Address - Country:US
Practice Address - Phone:706-736-1830
Practice Address - Fax:706-736-4521
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018206174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00263238A2Medicaid
GA00263238A2Medicaid