Provider Demographics
NPI:1215913090
Name:POLEN, THOMAS ALAN (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALAN
Last Name:POLEN
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 1:845 82ND PKWY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4614
Mailing Address - Country:US
Mailing Address - Phone:843-449-9621
Mailing Address - Fax:843-449-4921
Practice Address - Street 1:845 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4614
Practice Address - Country:US
Practice Address - Phone:843-449-9621
Practice Address - Fax:843-449-4921
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9075208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC090751Medicaid
SCB92554782Medicare ID - Type Unspecified
B92555Medicare UPIN