MEDICARE: DR. MARK J POLIS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	MD028607E	PA

General Provider Information

NPI Number	:	1548373939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK J POLIS M.D.

Provider Business Mailing Address
First Line	:	240 MONTAUK CIR
Second Line	:
City	:	PORT MATILDA
State	:	PA
Zip	:	16870-7314
Country	:	US
Telephone Number	:	814-867-3953
Fax Number	:

Provider Business Practice Location Address
First Line	:	240 MONTAUK CIR
Second Line	:
City	:	PORT MATILDA
State	:	PA
Zip	:	16870-7314
Country	:	US
Telephone Number	:	814-867-3953
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	09/17/2012

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