Healthcare Provider Details

I. General information

NPI: 1437252780
Provider Name (Legal Business Name): SAMUEL C POLK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 AIRWAYS BLVD STE 2
SOUTHAVEN MS
38671-4113
US

IV. Provider business mailing address

PO BOX 649113
DALLAS TX
75264-9113
US

V. Phone/Fax

Practice location:
  • Phone: 601-420-2040
  • Fax: 855-343-5763
Mailing address:
  • Phone: 903-571-3844
  • Fax: 855-343-5763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number41433
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number34003
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number34003
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: