Provider Demographics
NPI:1356430078
Name:PREMIER PODIATRY OF VIRGINIA LLC
Entity type:Organization
Organization Name:PREMIER PODIATRY OF VIRGINIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANKLIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:POLUN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:410-654-8602
Mailing Address - Street 1:10989 RED RUN BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-3283
Mailing Address - Country:US
Mailing Address - Phone:410-654-8602
Mailing Address - Fax:410-654-8709
Practice Address - Street 1:10989 RED RUN BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-3283
Practice Address - Country:US
Practice Address - Phone:410-654-8602
Practice Address - Fax:410-654-8709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCG01861Medicare PIN
VAC09063Medicare PIN