Basic Information
| Provider Information | |||||||||
| NPI: | 1609899558 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POLASCIK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 RIVERSIDE PKWY | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300435925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702373475 | ||||||||
| FaxNumber: | 7702373756 | ||||||||
| Practice Location | |||||||||
| Address1: | 3708 NORTHSIDE DR | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312102404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787454206 | ||||||||
| FaxNumber: | 4782545463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 09/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3716 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 003158408A | 05 | GA | MEDICAID |