Provider Demographics
NPI:1578958807
Name:POLAK, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:POLAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 S RACE ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-5707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17 E 102ND ST
Practice Address - Street 2:7TH FLOOR #1087
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-5204
Practice Address - Country:US
Practice Address - Phone:212-659-8551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program