Provider Demographics
NPI:1598872525
Name:POLANSKY, GINA RENAE
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:RENAE
Last Name:POLANSKY
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 1:504 KEENE DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8027
Mailing Address - Country:US
Mailing Address - Phone:970-219-2459
Mailing Address - Fax:
Practice Address - Street 1:370 E HERSEY ST STE 1
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2325
Practice Address - Country:US
Practice Address - Phone:541-482-6360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO8666OtherLICENSE #
OR60382OtherSTATE OF OREGON PHYSICAL THERAPY LICENSING BOARD