MEDICARE: MR. ILIR POLOVINA NP-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	363L00000X	Nurse Practitioner	2003005393	MO

General Provider Information

NPI Number	:	1952540999
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ILIR POLOVINA NP-C

Provider Business Mailing Address
First Line	:	12345 W BEND DR STE 200
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-2253
Country	:	US
Telephone Number	:	314-843-8000
Fax Number	:	314-843-3004

Provider Business Practice Location Address
First Line	:	12345 W BEND DR STE 200
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-2253
Country	:	US
Telephone Number	:	314-843-8000
Fax Number	:	314-843-3004

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

Provider Enumeration Date	:	02/16/2009
Last Update Date	:	02/16/2009

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