Healthcare Provider Details

I. General information

NPI: 1336187814
Provider Name (Legal Business Name): ELENA L POLUKHIN MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 UTAH AVE S SUITE 200
SAINT LOUIS PARK MN
55426-3671
US

IV. Provider business mailing address

3006 FRANK ST
MAPLEWOOD MN
55109-5501
US

V. Phone/Fax

Practice location:
  • Phone: 952-933-1121
  • Fax: 952-945-9536
Mailing address:
  • Phone: 651-699-0633
  • Fax: 651-797-3592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number45600
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: