Healthcare Provider Details

I. General information

NPI: 1811982671
Provider Name (Legal Business Name): EDWARD PHILLIPS POLACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PARK SUITE 704
WHEELING WV
26003
US

IV. Provider business mailing address

1 MEDICAL PARK SUITE 704
WHEELING WV
26003
US

V. Phone/Fax

Practice location:
  • Phone: 304-243-3134
  • Fax: 304-243-3834
Mailing address:
  • Phone: 304-243-3134
  • Fax: 304-243-3834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number35047399
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number11955
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number35047399
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number11955
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: