Provider Demographics
NPI:1760768246
Name:TARA POLSON
Entity Type:Organization
Organization Name:TARA POLSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDEIROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-356-2546
Mailing Address - Street 1:1915 EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-5027
Mailing Address - Country:US
Mailing Address - Phone:912-353-3079
Mailing Address - Fax:
Practice Address - Street 1:1915 EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-5027
Practice Address - Country:US
Practice Address - Phone:912-353-3079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003415283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital