Healthcare Provider Details

I. General information

NPI: 1891204970
Provider Name (Legal Business Name): RONALD LAVERN POLHILL JR. CPNP, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 SOUTH LINCOLN ST.
BAY CITY MI
48708
US

IV. Provider business mailing address

1648 N HURON RD
PINCONNING MI
48650-9509
US

V. Phone/Fax

Practice location:
  • Phone: 989-895-9876
  • Fax: 989-895-9780
Mailing address:
  • Phone: 989-879-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number4704222452
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704222452
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: