Provider Demographics
NPI:1184958712
Name:MICHAEL POLISENO FAMILY HEALTH NURSE PRACTITIONER PC
Entity type:Organization
Organization Name:MICHAEL POLISENO FAMILY HEALTH NURSE PRACTITIONER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:POLISENO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:516-375-5904
Mailing Address - Street 1:2094 MERRICK AVE
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-3147
Mailing Address - Country:US
Mailing Address - Phone:516-375-5904
Mailing Address - Fax:516-804-2784
Practice Address - Street 1:2094 MERRICK AVE
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-3147
Practice Address - Country:US
Practice Address - Phone:516-375-5904
Practice Address - Fax:516-804-2784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-29
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333205363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100021981OtherMEDICARE PTAN