Provider Demographics
NPI:1477534931
Name:POLLEY, JOHN WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:POLLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:WILLIAM
Other - Last Name:POLLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5085 ANNA DR STE A
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7475
Mailing Address - Country:US
Mailing Address - Phone:231-935-0180
Mailing Address - Fax:231-935-0099
Practice Address - Street 1:5085 ANNA DR STE A
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7475
Practice Address - Country:US
Practice Address - Phone:231-935-0180
Practice Address - Fax:231-935-0099
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301403808208200000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079739Medicaid
MI0B80405OtherBCBSMI
IL21623004OtherBCBS PROVIDER #
IL21623004OtherBCBS PROVIDER #
ILE68962Medicare UPIN
IL036079739Medicaid