=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881092336
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL H POLCINO, MD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2014
-----------------------------------------------------
Last Update Date | 12/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 796 DEER PARK AVE
-----------------------------------------------------
City | NORTH BABYLON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11703-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-482-8134
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 796 DEER PARK AVE
-----------------------------------------------------
City | NORTH BABYLON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11703-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-482-8134
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL POLCINO III
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 631-482-8134
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208C00000X
-----------------------------------------------------
Taxonomy Name | Colon & Rectal Surgery Physician
-----------------------------------------------------
License Number | 254871
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------