Provider Demographics
NPI:1528456779
Name:PSYCHIATRY 280, P.C.
Entity type:Organization
Organization Name:PSYCHIATRY 280, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:POLEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-499-1629
Mailing Address - Street 1:3840 REDDICK RD
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:TN
Mailing Address - Zip Code:37142-2141
Mailing Address - Country:US
Mailing Address - Phone:256-499-1629
Mailing Address - Fax:423-523-0994
Practice Address - Street 1:2803 GREYSTONE COMMERCIAL BLVD STE 12
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-9603
Practice Address - Country:US
Practice Address - Phone:205-968-1227
Practice Address - Fax:205-968-1229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-22
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD328342084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL171037Medicaid