Healthcare Provider Details

I. General information

NPI: 1861670275
Provider Name (Legal Business Name): POLLACK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1699 KING ST SUITE 208
ENFIELD CT
06082-6051
US

IV. Provider business mailing address

1699 KING STREET SUITE 208
ENFIELD CT
06082-4585
US

V. Phone/Fax

Practice location:
  • Phone: 860-749-5881
  • Fax: 860-776-2420
Mailing address:
  • Phone: 860-749-5881
  • Fax: 860-776-2420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number041022
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number041022
License Number StateCT

VIII. Authorized Official

Name: IRA A POLLACK
Title or Position: OWNER
Credential:
Phone: 860-749-5881