Healthcare Provider Details

I. General information

NPI: 1073446407
Provider Name (Legal Business Name): MAGEN RAYE POLCZYNSKI DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MELLON WAY
LATROBE PA
15650-1197
US

IV. Provider business mailing address

19 W 2ND AVE
LATROBE PA
15650-1167
US

V. Phone/Fax

Practice location:
  • Phone: 724-537-1485
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOT025625
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: