Provider Demographics
NPI:1124062690
Name:POLLOM, STEPHEN H (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:H
Last Name:POLLOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-962-3834
Mailing Address - Fax:
Practice Address - Street 1:1115 RONALD REAGAN PKWY
Practice Address - Street 2:STE 318
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-6910
Practice Address - Country:US
Practice Address - Phone:317-217-2600
Practice Address - Fax:317-217-2606
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024982A207R00000X
IN01024982207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100060460Medicaid
IN521070NMedicare PIN
IN100060460Medicaid
INP00859180Medicare PIN
INM400015464Medicare PIN