Provider Demographics
NPI:1699058958
Name:MEDICAL OFFICE OF DOCTOR ILONA K POLAK PC
Entity type:Organization
Organization Name:MEDICAL OFFICE OF DOCTOR ILONA K POLAK PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:ILONA
Authorized Official - Middle Name:K
Authorized Official - Last Name:POLAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-727-6284
Mailing Address - Street 1:PO BOX 2986
Mailing Address - Street 2:
Mailing Address - City:SAG HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11963-0402
Mailing Address - Country:US
Mailing Address - Phone:631-808-3337
Mailing Address - Fax:631-808-3338
Practice Address - Street 1:34 BAY ST # 103
Practice Address - Street 2:
Practice Address - City:SAG HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11963-3104
Practice Address - Country:US
Practice Address - Phone:631-808-3337
Practice Address - Fax:631-808-3338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-23
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY245282207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100062532Medicare PIN