1164435293 NPI number — DR. STANLEY ANTHONY POLIT MD

Table of content: DR. STANLEY ANTHONY POLIT MD (NPI 1164435293)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164435293 NPI number — DR. STANLEY ANTHONY POLIT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLIT
Provider First Name:
STANLEY
Provider Middle Name:
ANTHONY
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:
1164435293
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13751 83RD AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLAND PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60462-7007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-460-9346
Provider Business Mailing Address Fax Number:
708-424-1799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2850 WEST 95TH STREET
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
EVERGREEN PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-424-9044
Provider Business Practice Location Address Fax Number:
708-424-1799
Provider Enumeration Date:
08/13/2006

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: 207R00000X , with the licence number:  036064603 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 036064603 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036064603 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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