Provider Demographics
NPI:1780652909
Name:POLIDORO, MICHELE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:POLIDORO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:108 W MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-6773
Practice Address - Country:US
Practice Address - Phone:336-243-7054
Practice Address - Fax:336-243-2302
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200800806207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
38H991OtherBCBS
200921OtherGHI
NC2022373AOtherMEDICARE PTAN, INDIVIDUAL FOR WILKES
113510097OtherISLAND GROUP ADMINISTRATO
MP0427139OtherMALPRACTICE POLICY
AA01072OtherMDNY
113510097OtherFIRST HEALTH
113510097OtherMAGNACARE
33D0967171OtherCLIA
113510097OtherAARP
910931OtherIVR ACC CODE
10119OtherANTHEM
1049966OtherEMPIRE
113510097OtherLOCAL 1199
113510097OtherIEC BENEFIT ADMINISTRATOR
2504OtherINDEPENDENT HEALTH
6431110003OtherCIGNA HMO
6431110006OtherCIGNA SENIOR
113510097OtherISLAND GROUP ADMINISTRATO
F51754Medicare UPIN
F51754Medicare UPIN