MEDICARE: PSYCHIATRY 280, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	MD32834	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528456779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHIATRY 280, P.C.

Provider Business Mailing Address
First Line	:	3840 REDDICK RD
Second Line	:
City	:	PALMYRA
State	:	TN
Zip	:	37142-2141
Country	:	US
Telephone Number	:	256-499-1629
Fax Number	:	423-523-0994

Provider Business Practice Location Address
First Line	:	2803 GREYSTONE COMMERCIAL BLVD STE 12
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35242-9603
Country	:	US
Telephone Number	:	205-968-1227
Fax Number	:	205-968-1229

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SAMUEL ANDREW POLEK
Credential	:	MD
Telephone Number	:	256-499-1629

Provider Enumeration Date	:	12/22/2014
Last Update Date	:	10/02/2023

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