1780652909 NPI number — MICHELE POLIDORO MD

Table of content: MICHELE POLIDORO MD (NPI 1780652909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780652909 NPI number — MICHELE POLIDORO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLIDORO
Provider First Name:
MICHELE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1780652909
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60447
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-0447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 W MEDICAL PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27292-6773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-243-7054
Provider Business Practice Location Address Fax Number:
336-243-2302
Provider Enumeration Date:
03/14/2006

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: 207V00000X , with the licence number:  200800806 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 38H991 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200921 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2022373A . This is a "MEDICARE PTAN, INDIVIDUAL FOR WILKES" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 113510097 . This is a "ISLAND GROUP ADMINISTRATO" identifier . This identifiers is of the category "OTHER".
  • Identifier: MP0427139 . This is a "MALPRACTICE POLICY" identifier . This identifiers is of the category "OTHER".
  • Identifier: AA01072 . This is a "MDNY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 113510097 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 113510097 . This is a "MAGNACARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 33D0967171 . This is a "CLIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 113510097 . This is a "AARP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 910931 . This is a "IVR ACC CODE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10119 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1049966 . This is a "EMPIRE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 113510097 . This is a "LOCAL 1199" identifier . This identifiers is of the category "OTHER".
  • Identifier: 113510097 . This is a "IEC BENEFIT ADMINISTRATOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2504 . This is a "INDEPENDENT HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6431110003 . This is a "CIGNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6431110006 . This is a "CIGNA SENIOR" identifier . This identifiers is of the category "OTHER".




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