Provider Demographics
NPI:1376689711
Name:POLK PEDIATRICS
Entity Type:Organization
Organization Name:POLK PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANANTHAKRISHNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PILLAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-534-3737
Mailing Address - Street 1:1265 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-5006
Mailing Address - Country:US
Mailing Address - Phone:863-534-3737
Mailing Address - Fax:863-533-6323
Practice Address - Street 1:1265 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-5006
Practice Address - Country:US
Practice Address - Phone:863-534-3737
Practice Address - Fax:863-533-6323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0029864208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067708600Medicaid
FL59264OtherBCBS ID #