Provider Demographics
NPI:1558307603
Name:POLTORAK, EWA (MD)
Entity Type:Individual
Prefix:MS
First Name:EWA
Middle Name:
Last Name:POLTORAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 ELM STREET
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-4158
Mailing Address - Country:US
Mailing Address - Phone:847-687-6759
Mailing Address - Fax:847-730-3729
Practice Address - Street 1:503 ELM STREET
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-4158
Practice Address - Country:US
Practice Address - Phone:847-687-6759
Practice Address - Fax:847-730-3729
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058615207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H47233Medicare UPIN