Provider Demographics
NPI:1427372994
Name:IRA POLLACK MD PC
Entity Type:Organization
Organization Name:IRA POLLACK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IRA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-749-5881
Mailing Address - Street 1:1699 KING STREET
Mailing Address - Street 2:SUITE 208
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082
Mailing Address - Country:US
Mailing Address - Phone:860-749-5881
Mailing Address - Fax:860-776-2420
Practice Address - Street 1:1699 KING STREET
Practice Address - Street 2:SUITE 208
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082
Practice Address - Country:US
Practice Address - Phone:860-749-5881
Practice Address - Fax:860-776-2420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-26
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA217519207RS0012X
CT0410222084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001410224Medicaid
CTC44412Medicare UPIN
CTD100013952Medicare PIN