Provider Demographics
NPI:1841392636
Name:POLACEK, LORI G (MD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:G
Last Name:POLACEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1524 ATWOOD AVE
Mailing Address - Street 2:SUITE 343
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919
Mailing Address - Country:US
Mailing Address - Phone:401-331-0202
Mailing Address - Fax:401-421-3353
Practice Address - Street 1:1524 ATWOOD AVE
Practice Address - Street 2:SUITE 343
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919
Practice Address - Country:US
Practice Address - Phone:401-331-0202
Practice Address - Fax:401-421-3353
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIRI8046208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9020105Medicaid
RI249020105Medicare ID - Type Unspecified
RI9020105Medicaid