Provider Demographics
NPI:1801853866
Name:RICHARD J. POLLACK, D.O., S.C.
Entity Type:Organization
Organization Name:RICHARD J. POLLACK, D.O., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:POLLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:262-646-3302
Mailing Address - Street 1:2574 SUN VALLEY DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-2334
Mailing Address - Country:US
Mailing Address - Phone:262-646-3302
Mailing Address - Fax:
Practice Address - Street 1:2574 SUN VALLEY DR
Practice Address - Street 2:SUITE 206
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-2334
Practice Address - Country:US
Practice Address - Phone:262-646-3302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31382900Medicare ID - Type Unspecified
WI368835Medicare ID - Type Unspecified