Basic Information
| Provider Information | |||||||||
| NPI: | 1932547767 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POLESTAR MEDICAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 204476 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753204476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813463480 | ||||||||
| FaxNumber: | 2814624106 | ||||||||
| Practice Location | |||||||||
| Address1: | 5005 W ROYAL LN STE 196 | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750631959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813463480 | ||||||||
| FaxNumber: | 2814624106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2013 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | KROPHOLLER | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2542212900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | N | 193400000X SINGLE SPECIALTY GROUP | 2084N0600X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
No ID Information.