Provider Demographics
NPI:1316912132
Name:CHARLES T POLIS JR MD PA
Entity type:Organization
Organization Name:CHARLES T POLIS JR MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:T
Authorized Official - Last Name:POLIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:941-792-1477
Mailing Address - Street 1:1410 59TH STREET W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209
Mailing Address - Country:US
Mailing Address - Phone:941-792-1477
Mailing Address - Fax:941-794-8017
Practice Address - Street 1:1410 59TH STREET W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209
Practice Address - Country:US
Practice Address - Phone:941-792-1477
Practice Address - Fax:941-794-8017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340003525OtherRAILROAD MEDICARE
FL99145Medicare PIN
FL0837840001Medicare NSC