=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366472946
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARSHALL SANDY POLLACK MK.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2006
-----------------------------------------------------
Last Update Date | 02/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 233 MILLBURN AVE
-----------------------------------------------------
City | MILLBURN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07041-1718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-467-9440
-----------------------------------------------------
Fax | 973-376-1680
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 233 MILLBURN AVE
-----------------------------------------------------
City | MILLBURN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07041-1718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-467-9440
-----------------------------------------------------
Fax | 973-376-1680
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | MA035089
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------