Provider Demographics
NPI:1285634501
Name:POLOS, PETER G (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:POLOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-3947
Mailing Address - Country:US
Mailing Address - Phone:732-321-7010
Mailing Address - Fax:732-744-5873
Practice Address - Street 1:65 JAMES ST
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3947
Practice Address - Country:US
Practice Address - Phone:732-321-7010
Practice Address - Fax:732-744-5873
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07459300207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0041599Medicaid
NJ154779AJBMedicare PIN
E81636Medicare UPIN