Provider Demographics
NPI:1346211455
Name:POLANCO, JORGE (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:POLANCO
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:PO BOX 60274
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0274
Mailing Address - Country:US
Mailing Address - Phone:843-237-3378
Mailing Address - Fax:843-237-5073
Practice Address - Street 1:262 LEROY GEORGE DR
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:NC
Practice Address - Zip Code:28721-7430
Practice Address - Country:US
Practice Address - Phone:843-237-3378
Practice Address - Fax:843-237-5073
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200201300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891323KMedicaid
NC1323KOtherBCBS
NCP00201238OtherRAILROAD
NCH78890Medicare UPIN
NCP00201238OtherRAILROAD