Provider Demographics
NPI:1063402352
Name:POLYKOFF, GARY I (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:I
Last Name:POLYKOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:15 PARKMAN ST
Practice Address - Street 2:WAC 340 ANESTHESIA PAIN MANAGEMENT
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-726-3512
Practice Address - Fax:617-726-3519
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2011-09-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA81894208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3186733Medicaid
MAJ19417OtherBCBS MA
MA081894OtherTUFTS HEALTH PLAN
MA081894OtherTUFTS HEALTH PLAN
MA3186733Medicaid