Healthcare Provider Details

I. General information

NPI: 1871620112
Provider Name (Legal Business Name): MICHAEL JOHN POLISIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 MAPLE ST SUITE 107
SUMMIT NJ
07901-2571
US

IV. Provider business mailing address

47 MAPLE ST SUITE 107
SUMMIT NJ
07901-2571
US

V. Phone/Fax

Practice location:
  • Phone: 908-273-5866
  • Fax: 908-273-5811
Mailing address:
  • Phone: 908-273-5866
  • Fax: 908-273-5811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMA49436
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: