Provider Demographics
NPI:1871672386
Name:POLSON, ERIC B (PT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:B
Last Name:POLSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7581 9TH ST N STE 100
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6635
Mailing Address - Country:US
Mailing Address - Phone:651-748-4338
Mailing Address - Fax:
Practice Address - Street 1:1935 COUNTY ROAD B2 W STE 405
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-2797
Practice Address - Country:US
Practice Address - Phone:651-635-0578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2601225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN990824200Medicaid
MN650000180Medicare PIN