Provider Demographics
NPI:1760830004
Name:POLAND, MELISSA
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:
Last Name:POLAND
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 1:119 EDGAR AVE
Mailing Address - Street 2:
Mailing Address - City:ASTON
Mailing Address - State:PA
Mailing Address - Zip Code:19014-2703
Mailing Address - Country:US
Mailing Address - Phone:267-854-1096
Mailing Address - Fax:
Practice Address - Street 1:713 S JUNIPER ST
Practice Address - Street 2:APT B
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-2607
Practice Address - Country:US
Practice Address - Phone:267-423-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-26
Last Update Date:2024-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA8469161744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3053Medicare PIN