Healthcare Provider Details

I. General information

NPI: 1871559740
Provider Name (Legal Business Name): ETHAN G POLSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4712 N ARMENIA AVE SUITE 200
TAMPA FL
33603-2611
US

IV. Provider business mailing address

4712 N ARMENIA AVE SUITE 200
TAMPA FL
33603-2611
US

V. Phone/Fax

Practice location:
  • Phone: 813-874-7500
  • Fax: 813-877-1397
Mailing address:
  • Phone: 813-874-7500
  • Fax: 813-877-1397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberME95516
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: