Provider Demographics
NPI:1518997881
Name:POLAN, STACEY (DO)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:POLAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SNOWDEN RD
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-2633
Mailing Address - Country:US
Mailing Address - Phone:215-465-5607
Mailing Address - Fax:215-465-6830
Practice Address - Street 1:152 WOLF ST
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19148-3325
Practice Address - Country:US
Practice Address - Phone:215-465-5607
Practice Address - Fax:215-465-6830
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004495L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0908779Medicaid
PAPO431385Medicare ID - Type Unspecified
PA0908779Medicaid