Provider Demographics
NPI:1063445112
Name:POLING, RODNEY H (DO)
Entity Type:Individual
Prefix:DR
First Name:RODNEY
Middle Name:H
Last Name:POLING
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17740 FORT ST
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-6633
Mailing Address - Country:US
Mailing Address - Phone:734-284-0700
Mailing Address - Fax:734-284-7676
Practice Address - Street 1:17740 FORT ST
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-6633
Practice Address - Country:US
Practice Address - Phone:734-284-0700
Practice Address - Fax:734-284-7676
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1063445112OtherNPI
MI1060353-11Medicaid
MI1060353-11Medicaid
MI9823057Medicare ID - Type UnspecifiedMEDICARE