Provider Demographics
NPI:1063066371
Name:POLEJAEV, MICHAEL ALEXANDER (DPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALEXANDER
Last Name:POLEJAEV
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ARDMORE AVE
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-1132
Mailing Address - Country:US
Mailing Address - Phone:215-900-7746
Mailing Address - Fax:
Practice Address - Street 1:825 OLD LANCASTER RD STE 140
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3234
Practice Address - Country:US
Practice Address - Phone:800-321-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT026425225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist