Provider Demographics
NPI:1891027512
Name:POLHEMUS, MARK EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:POLHEMUS
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 1:715 DR MARTIN LUTHER KING JR AVE NE STE 201
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3667
Mailing Address - Country:US
Mailing Address - Phone:505-727-3020
Mailing Address - Fax:505-727-9590
Practice Address - Street 1:715 DR MARTIN LUTHER KING JR AVE NE STE 201
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3667
Practice Address - Country:US
Practice Address - Phone:505-727-3020
Practice Address - Fax:505-727-9590
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261872207RI0200X
NMMD2022-1151207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03368756Medicaid
NYJ400050837Medicare PIN
NYP01173399Medicare PIN