Basic Information
| Provider Information | |||||||||
| NPI: | 1003554999 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POLARIS CARE MEDICAL PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 79 FLAGG CT | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103041157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6464092508 | ||||||||
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| Practice Location | |||||||||
| Address1: | 824 55TH ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112203245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184351025 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2022 | ||||||||
| LastUpdateDate: | 05/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | LIU | ||||||||
| AuthorizedOfficialFirstName: | CHE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6464092508 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Acupuncturist | 2083P0500X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Preventive Medicine/Occupational Environmental Medicine |
ID Information
| ID | Type | State | Issuer | Description | 309005 | 01 | NY | MEDICINE AND SURGERY LICENSE | OTHER |