1699756544 NPI number — MRS. DEEANN MAE POLAKOVSKY PAC

Table of content: MRS. DEEANN MAE POLAKOVSKY PAC (NPI 1699756544)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699756544 NPI number — MRS. DEEANN MAE POLAKOVSKY PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLAKOVSKY
Provider First Name:
DEEANN
Provider Middle Name:
MAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PEARSON
Provider Other First Name:
DEANN
Provider Other Middle Name:
MAE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699756544
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 MULBERRY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCOTTDALE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15683-1704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-887-3911
Provider Business Mailing Address Fax Number:
724-220-5036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 MULBERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTDALE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15683-1704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-887-3911
Provider Business Practice Location Address Fax Number:
724-220-5036
Provider Enumeration Date:
11/08/2005

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: 363AM0700X , with the licence number:  MA003596L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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