Basic Information
| Provider Information | |||||||||
| NPI: | 1114177938 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOSE F POLANCO MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 3RD AVE E | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342081014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417083358 | ||||||||
| FaxNumber: | 9417491046 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 3RD AVE E | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342081014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417083358 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2008 | ||||||||
| LastUpdateDate: | 08/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | POLANCO | ||||||||
| AuthorizedOfficialFirstName: | JOSE | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9417083358 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME73836 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003131900 | 05 | FL | MEDICAID |