Healthcare Provider Details

I. General information

NPI: 1477744621
Provider Name (Legal Business Name): MARTHA POLOVICH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 08/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 TOWER BLVD SUITE 600
DURHAM NC
27707-2563
US

IV. Provider business mailing address

3100 TOWER BLVD SUITE 600
DURHAM NC
27707-2563
US

V. Phone/Fax

Practice location:
  • Phone: 919-419-5051
  • Fax: 919-493-3234
Mailing address:
  • Phone: 919-419-5051
  • Fax: 919-493-3234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberRN 109632
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: