MEDICARE: IRINA Y POLANSKY PA-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	363A00000X	Physician Assistant	085002586	IL

General Provider Information

NPI Number	:	1801866462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRINA Y POLANSKY PA-C

Provider Business Mailing Address
First Line	:	130 LINCOLN PLACE CT STE 130
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62221-5884
Country	:	US
Telephone Number	:	618-257-1297
Fax Number	:	618-257-1529

Provider Business Practice Location Address
First Line	:	130 LINCOLN PLACE CT STE 130
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62221-5884
Country	:	US
Telephone Number	:	618-257-1297
Fax Number	:	618-277-1190

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	03/03/2021

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