Healthcare Provider Details

I. General information

NPI: 1205255015
Provider Name (Legal Business Name): AMANDA GAIL POLSINELLI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 J CLYDE MORRIS BLVD STE A
NEWPORT NEWS VA
23601
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD STE A
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 757-594-3969
  • Fax: 757-534-5190
Mailing address:
  • Phone: 757-594-3969
  • Fax: 757-534-5190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35.130657
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number57.024658
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101262824
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: