Provider Demographics
NPI:1851305270
Name:DR POKOVS POLYCLINIC PC
Entity Type:Organization
Organization Name:DR POKOVS POLYCLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:POKOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-358-9158
Mailing Address - Street 1:6821 REISTERSTOWN RD
Mailing Address - Street 2:SUITE #206
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215
Mailing Address - Country:US
Mailing Address - Phone:410-358-9158
Mailing Address - Fax:410-358-6350
Practice Address - Street 1:6821 REISTERSTOWN RD
Practice Address - Street 2:SUITE #206
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215
Practice Address - Country:US
Practice Address - Phone:410-358-9158
Practice Address - Fax:410-358-6350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0054746207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0P64OtherBLUE CROSS BLUE SHIELD
MD682505200Medicaid
MD0P64OtherBLUE CROSS BLUE SHIELD
MD682505200Medicaid