Provider Demographics
NPI:1518164417
Name:POLK COUNTY ADULT HEALTH CARE PA
Entity Type:Organization
Organization Name:POLK COUNTY ADULT HEALTH CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PONGOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-318-1111
Mailing Address - Street 1:4842 CYPRESS GARDENS RD
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-2908
Mailing Address - Country:US
Mailing Address - Phone:863-318-1111
Mailing Address - Fax:863-318-1102
Practice Address - Street 1:4842 CYPRESS GARDENS RD
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-2908
Practice Address - Country:US
Practice Address - Phone:863-318-1111
Practice Address - Fax:863-318-1102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80722207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5532Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER