Provider Demographics
NPI:1285640557
Name:POLUBINSKY, LAURIE J (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:J
Last Name:POLUBINSKY
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 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:1836 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5429
Practice Address - Country:US
Practice Address - Phone:608-782-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010591872084P0800X
OH350904202084P0800X
WI432422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200488180Medicaid
OHH34308Medicare UPIN
INH34308Medicare UPIN
IN151020NNMedicare ID - Type Unspecified
IN200488180Medicaid