Healthcare Provider Details

I. General information

NPI: 1801460613
Provider Name (Legal Business Name): NICHOLAS JAMES POLAKOWSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE STE A601
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

1632 STONE ST
SAGINAW MI
48602
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-3570
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number4351051089
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: