Provider Demographics
NPI:1225226079
Name:POLLACK, REBECCA IDA (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:IDA
Last Name:POLLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:905 KENILWORTH AVE
Practice Address - Street 2:UNIT A
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-1015
Practice Address - Country:US
Practice Address - Phone:704-355-3149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-01288207V00000X, 207VM0101X, 207VM0101X
NC01288207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC1863Medicaid
NC1225226079Medicaid
SCNC1863Medicaid