Provider Demographics
NPI:1235369588
Name:ROBERT W. POLLACK, MD, PLLC
Entity Type:Organization
Organization Name:ROBERT W. POLLACK, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:POLLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-231-4258
Mailing Address - Street 1:2665 CLEVELAND AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-5850
Mailing Address - Country:US
Mailing Address - Phone:321-229-9750
Mailing Address - Fax:
Practice Address - Street 1:2665 CLEVELAND AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5850
Practice Address - Country:US
Practice Address - Phone:321-229-9750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME26270103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBZ258AMedicare PIN