1083702070 NPI number — MICHAEL F POLISE D.O

Table of content: MICHAEL F POLISE D.O (NPI 1083702070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083702070 NPI number — MICHAEL F POLISE D.O

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLISE
Provider First Name:
MICHAEL
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083702070
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10850 W. PARK PLACE
Provider Second Line Business Mailing Address:
SUITE 1100
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53224-3606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-359-5745
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
640 S STATE STREET
Provider Second Line Business Practice Location Address:
DEPT OF RADIOLOGY
Provider Business Practice Location Address City Name:
DOVER
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19901-3530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-674-2202
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  C2-0005715 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)