Healthcare Provider Details

I. General information

NPI: 1871635458
Provider Name (Legal Business Name): EDWARD S POLASHENSKI DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 WEST 14TH ST
HAZLETON PA
18201-3266
US

IV. Provider business mailing address

128 W 14TH ST
HAZLETON PA
18201-3266
US

V. Phone/Fax

Practice location:
  • Phone: 570-455-7677
  • Fax: 570-455-7627
Mailing address:
  • Phone: 570-455-7677
  • Fax: 570-455-7627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS 004597 L
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD 031594 E
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD 031594 E
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberOS 004597 L
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier182462
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE SHIELD
# 2
Identifier0010850580001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 3
Identifier122500
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE SHIELD
# 4
Identifier0010140830002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: EDWARD S POLASHENSKI
Title or Position: PRESIDENT
Credential: DO FACOI
Phone: 570-455-7677