Provider Demographics
NPI:1871685206
Name:POLOVITZ, THOMAS M (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:M
Last Name:POLOVITZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 NW 7TH ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-2912
Mailing Address - Country:US
Mailing Address - Phone:218-855-1115
Mailing Address - Fax:218-855-1183
Practice Address - Street 1:722 NW 7TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-2912
Practice Address - Country:US
Practice Address - Phone:218-855-1115
Practice Address - Fax:218-855-1183
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4117207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12473Medicare PIN
D26220Medicare UPIN