Healthcare Provider Details

I. General information

NPI: 1376689711
Provider Name (Legal Business Name): POLK PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 03/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 E MAIN ST
BARTOW FL
33830-5006
US

IV. Provider business mailing address

1265 E MAIN ST
BARTOW FL
33830-5006
US

V. Phone/Fax

Practice location:
  • Phone: 863-534-3737
  • Fax: 863-533-6323
Mailing address:
  • Phone: 863-534-3737
  • Fax: 863-533-6323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0029864
License Number StateFL

VIII. Authorized Official

Name: DR. ANANTHAKRISHNA PILLAI
Title or Position: DOCTOR
Credential: MD
Phone: 863-534-3737