Provider Demographics
NPI:1659645083
Name:CHARLES POLSEN MD PA LLC
Entity Type:Organization
Organization Name:CHARLES POLSEN MD PA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:POLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-538-6600
Mailing Address - Street 1:2622 MARINA BAY DR
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-2758
Mailing Address - Country:US
Mailing Address - Phone:281-538-6600
Mailing Address - Fax:281-535-2800
Practice Address - Street 1:2622 MARINA BAY DR
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-2758
Practice Address - Country:US
Practice Address - Phone:281-538-6600
Practice Address - Fax:281-535-2800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ29022082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Single Specialty