Provider Demographics
NPI:1386492726
Name:POLARIS MEDICAL GROUP PA
Entity type:Organization
Organization Name:POLARIS MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAISON
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSEPH LUKE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN FNP-BC
Authorized Official - Phone:407-729-4298
Mailing Address - Street 1:1705 LAKELAND HILLS BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3061
Mailing Address - Country:US
Mailing Address - Phone:863-688-6051
Mailing Address - Fax:938-336-2587
Practice Address - Street 1:1705 LAKELAND HILLS BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3061
Practice Address - Country:US
Practice Address - Phone:863-688-6051
Practice Address - Fax:938-336-2587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty