Provider Demographics
NPI:1013931245
Name:POLNEROW, MARTIN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:
Last Name:POLNEROW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RAMBLEWOOD CENTER
Mailing Address - Street 2:1155 RT.73 STE. J
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054
Mailing Address - Country:US
Mailing Address - Phone:856-235-2505
Mailing Address - Fax:856-235-6425
Practice Address - Street 1:RAMBLEWOOD CENTER
Practice Address - Street 2:1155 RT.73 STE. J
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054
Practice Address - Country:US
Practice Address - Phone:856-235-2505
Practice Address - Fax:856-235-6425
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB023117207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE06050Medicare UPIN
NJ041934Medicare ID - Type Unspecified