Provider Demographics
NPI:1235824640
Name:POLK CONCIERGE MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:POLK CONCIERGE MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ASIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:STANDIFER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:352-807-2197
Mailing Address - Street 1:304 E PINE ST # 1143
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-4969
Mailing Address - Country:US
Mailing Address - Phone:863-339-2025
Mailing Address - Fax:
Practice Address - Street 1:304 E PINE ST # 1143
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-4969
Practice Address - Country:US
Practice Address - Phone:863-339-2025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty