Provider Demographics
NPI:1285773739
Name:POLAN, MARY-ANNE ANGELINE (OTR)
Entity type:Individual
Prefix:PROF
First Name:MARY-ANNE
Middle Name:ANGELINE
Last Name:POLAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39475 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:HARRISON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-1863
Mailing Address - Country:US
Mailing Address - Phone:586-465-3258
Mailing Address - Fax:
Practice Address - Street 1:22550 HALL RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1189
Practice Address - Country:US
Practice Address - Phone:586-466-7904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001745171W00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171W00000XOther Service ProvidersContractor