Provider Demographics
NPI:1255883336
Name:POLGA MEDICAL GROUP P A
Entity type:Organization
Organization Name:POLGA MEDICAL GROUP P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:POLGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-527-5275
Mailing Address - Street 1:PO BOX 566042
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33256-6042
Mailing Address - Country:US
Mailing Address - Phone:305-527-5275
Mailing Address - Fax:305-255-1669
Practice Address - Street 1:240 CRANDON BLVD STE 212
Practice Address - Street 2:
Practice Address - City:KEY BISCAYNE
Practice Address - State:FL
Practice Address - Zip Code:33149-1597
Practice Address - Country:US
Practice Address - Phone:305-967-7466
Practice Address - Fax:305-397-1076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85407207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H79186Medicare UPIN