Basic Information
Provider Information | |||||||||
NPI: | 1528456779 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PSYCHIATRY 280, P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14 BELLE POINT RD | ||||||||
Address2: |   | ||||||||
City: | BELFAST | ||||||||
State: | ME | ||||||||
PostalCode: | 049154265 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2059681227 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2803 GREYSTONE COMMERCIAL BLVD STE 12 | ||||||||
Address2: |   | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 352429603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2059681227 | ||||||||
FaxNumber: | 2059681229 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2014 | ||||||||
LastUpdateDate: | 11/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POLEK | ||||||||
AuthorizedOfficialFirstName: | SAMUEL | ||||||||
AuthorizedOfficialMiddleName: | ANDREW | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 2059681227 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 11/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD32834 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 171037 | 05 | AL |   | MEDICAID |