1659324465 NPI number — DR. DONOVAN C POLACK MD

Table of content: DR. DONOVAN C POLACK MD (NPI 1659324465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659324465 NPI number — DR. DONOVAN C POLACK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLACK
Provider First Name:
DONOVAN
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1659324465
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11155 DUNN RD STE 211N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63136-6166
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-741-1600
Provider Business Mailing Address Fax Number:
314-741-1677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11155 DUNN RD
Provider Second Line Business Practice Location Address:
SUITE 211N
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63136-6150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-741-1600
Provider Business Practice Location Address Fax Number:
314-741-1677
Provider Enumeration Date:
05/19/2006

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: 174400000X , with the licence number:  R5H69 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 036-072078 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X , with the licence number: R5H69 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 202546321 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 431965218 . This is a "EMPLOYER TAX ID" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".