Provider Demographics
NPI:1578922332
Name:POLSKY, ROGER (NP-C)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:POLSKY
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 PAMPLICO HWY STE A220
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-6056
Mailing Address - Country:US
Mailing Address - Phone:843-674-1530
Mailing Address - Fax:843-673-9098
Practice Address - Street 1:805 PAMPLICO HWY STE A220
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-6056
Practice Address - Country:US
Practice Address - Phone:843-674-1530
Practice Address - Fax:843-673-9098
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19955363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC19955OtherSTATE LICENSE