Basic Information
| Provider Information | |||||||||
| NPI: | 1891027512 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLHEMUS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 715 DR MARTIN LUTHER KING JR AVE NE STE 201 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871023667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057273020 | ||||||||
| FaxNumber: | 5057279590 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 DR MARTIN LUTHER KING JR AVE NE STE 201 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871023667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057273020 | ||||||||
| FaxNumber: | 5057279590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2010 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 261872 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | MD2022-1151 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 03368756 | 05 | NY | MEDICAID |