Provider Demographics
NPI:1609175819
Name:POLARIS PEDIATRICS INC
Entity Type:Organization
Organization Name:POLARIS PEDIATRICS INC
Other - Org Name:BRUCE MIRVIS, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MIRVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-437-5600
Mailing Address - Street 1:8947 ANTARES AVENUE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43240-2012
Mailing Address - Country:US
Mailing Address - Phone:614-437-5600
Mailing Address - Fax:614-985-1499
Practice Address - Street 1:8947 ANTARES AVENUE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43240-2012
Practice Address - Country:US
Practice Address - Phone:614-437-5600
Practice Address - Fax:614-985-1499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-28
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35039260208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0345086Medicaid
OHC02637Medicare UPIN