Healthcare Provider Details

I. General information

NPI: 1508174079
Provider Name (Legal Business Name): TOM POLAKOW RN, BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2010
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 FOLSOM ST STE B
SAN FRANCISCO CA
94107-1123
US

IV. Provider business mailing address

311 S BASSWOOD RD
LAKE FOREST IL
60045-2808
US

V. Phone/Fax

Practice location:
  • Phone: 415-723-2170
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number247217-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041386114
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: