Provider Demographics
NPI:1508174079
Name:POLAKOW, TOM (RN, BSN)
Entity type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:POLAKOW
Suffix:
Gender:M
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 S BASSWOOD RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-2808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 FRANK H OGAWA PLZ FL 7
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2006
Practice Address - Country:US
Practice Address - Phone:415-723-2170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-18
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI247217-30163W00000X
IL041386114163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse