MEDICARE: DR. ERIK POLDEMANN 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	390200000X	Student in an Organized Health Care Education/Training Program
2	207R00000X	Internal Medicine Physician	35.139384	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689069866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIK POLDEMANN M.D.

Provider Business Mailing Address
First Line	:	3170 KETTERING BLVD BLDG B
Second Line	:
City	:	MORAINE
State	:	OH
Zip	:	45439-1924
Country	:	US
Telephone Number	:	937-991-3188
Fax Number	:	372-239-8119

Provider Business Practice Location Address
First Line	:	1530 NEEDMORE RD STE 300
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45414-3980
Country	:	US
Telephone Number	:	937-276-4274
Fax Number	:	937-277-8476

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

Provider Enumeration Date	:	04/03/2015
Last Update Date	:	06/16/2022

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