MEDICARE: MS. MICHELLE GAIL POLK L.AC

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	171100000X	Acupuncturist	198.001227	IL

General Provider Information

NPI Number	:	1861881856
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MICHELLE GAIL POLK L.AC

Provider Business Mailing Address
First Line	:	3166 N LINCOLN AVE
Second Line	:	SUITE 405
City	:	CHICAGO
State	:	IL
Zip	:	60657-3133
Country	:	US
Telephone Number	:	847-769-3312
Fax Number	:

Provider Business Practice Location Address
First Line	:	1479 W WINONA ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-6819
Country	:	US
Telephone Number	:	847-769-3312
Fax Number	:

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

Provider Enumeration Date	:	01/14/2015
Last Update Date	:	02/26/2016

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