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General NPI Number Information
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NPI Number | 1265537021
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Entity Type | Individual
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Provider Name | FREDERICK LEON POLANDO P.A
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Gender | Male
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Dates
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Enumeration Date | 09/14/2006
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Last Update Date | 12/16/2014
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Provider Practice Location Address
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Address Line | 580 BLACK RIVER RD
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City | GEORGETOWN
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State | SC
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Zip | 29440-3302
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Country | US
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Telephone | 843-652-4000
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Fax | 843-652-4004
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Provider Business Mailing Address
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Address Line | 2234 COLONIAL BLVD ATTN: PAYER CONTRACTING & RELATIONS DEPT.
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City | FORT MYERS
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State | FL
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Zip | 33907-1412
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Country | US
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Telephone | 239-931-7342
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Fax | 239-931-7385
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | MA002186L
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | TL1940
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License Number State | SC
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