Healthcare Provider Details

I. General information

NPI: 1811758733
Provider Name (Legal Business Name): JERMAINE POLK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2024
Last Update Date: 01/18/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E LEIGH ST
RICHMOND VA
23298
US

IV. Provider business mailing address

11500 MAPLE LANDING PL
CHESTER VA
23831-7759
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-7247
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN310742
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: