Provider Demographics
NPI:1588656466
Name:POLITI, ROMAN E (MD)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:E
Last Name:POLITI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2837 US 41 WEST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-0220
Mailing Address - Country:US
Mailing Address - Phone:906-225-3964
Mailing Address - Fax:906-226-3875
Practice Address - Street 1:580 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2705
Practice Address - Country:US
Practice Address - Phone:906-225-3993
Practice Address - Fax:906-226-3875
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010675922084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4848623Medicaid
MI4938079Medicaid
MI130E26028OtherBLUE CROSS BLUE SHIELD MI
MI4305342Medicaid
MI4153840Medicaid
MI4132760Medicaid
MI4305342Medicaid
H01862Medicare UPIN
130021084Medicare PIN