Provider Demographics
NPI:1225233323
Name:POLK, RICHARD (PT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:POLK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N546 SCHROETER DR
Mailing Address - Street 2:
Mailing Address - City:RANDOM LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53075-1272
Mailing Address - Country:US
Mailing Address - Phone:920-207-3550
Mailing Address - Fax:920-994-4606
Practice Address - Street 1:N546 SCHROETER DR
Practice Address - Street 2:
Practice Address - City:RANDOM LAKE
Practice Address - State:WI
Practice Address - Zip Code:53075-1272
Practice Address - Country:US
Practice Address - Phone:920-207-3550
Practice Address - Fax:920-994-4606
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4734-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIPENDINGMedicare ID - Type Unspecified