Provider Demographics
NPI:1871635458
Name:EDWARD S POLASHENSKI DO PC
Entity Type:Organization
Organization Name:EDWARD S POLASHENSKI DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:POLASHENSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DO FACOI
Authorized Official - Phone:570-455-7677
Mailing Address - Street 1:128 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18201-3266
Mailing Address - Country:US
Mailing Address - Phone:570-455-7677
Mailing Address - Fax:570-455-7627
Practice Address - Street 1:128 WEST 14TH ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-3266
Practice Address - Country:US
Practice Address - Phone:570-455-7677
Practice Address - Fax:570-455-7627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OS 004597 L207R00000X, 207RG0100X
MD 031594 E207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA182462OtherBLUE SHIELD
PA0010850580001Medicaid
PA122500OtherBLUE SHIELD
PA0010140830002Medicaid
PA122500OtherBLUE SHIELD
B37253Medicare UPIN
PA122500Medicare ID - Type Unspecified
PA124563Medicare PIN
PA182462Medicare ID - Type Unspecified