Healthcare Provider Details

I. General information

NPI: 1831930072
Provider Name (Legal Business Name): RAFAEL M POLANCO HOUSE PHYSICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9333 SW 152ND ST
PALMETTO BAY FL
33157-1778
US

IV. Provider business mailing address

15049 SW 141ST TER
MIAMI FL
33196-4691
US

V. Phone/Fax

Practice location:
  • Phone: 305-251-2500
  • Fax:
Mailing address:
  • Phone: 786-317-6967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberHSE2857
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: