Basic Information
| Provider Information | |||||||||
| NPI: | 1609850411 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLANCO | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | ROMAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39 BARTLETT AVE | ||||||||
| Address2: | |||||||||
| City: | CRANSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029051334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015293571 | ||||||||
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| Practice Location | |||||||||
| Address1: | 31 ROCHE BROS WAY | ||||||||
| Address2: | |||||||||
| City: | NORTH EASTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023561032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088948730 | ||||||||
| FaxNumber: | 5088948732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 06/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD10514 | RI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 273647 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | S400453494 | 01 | MA | MEDICARE | OTHER | 110131381A | 05 | MA | MEDICAID | 7009048 | 05 | RI | MEDICAID |