Provider Demographics
NPI:1811982671
Name:POLACK, EDWARD PHILLIPS (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:PHILLIPS
Last Name:POLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL PARK
Mailing Address - Street 2:SUITE 704
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003
Mailing Address - Country:US
Mailing Address - Phone:304-243-3134
Mailing Address - Fax:304-243-3834
Practice Address - Street 1:1 MEDICAL PARK
Practice Address - Street 2:SUITE 704
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003
Practice Address - Country:US
Practice Address - Phone:304-243-3134
Practice Address - Fax:304-243-3834
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350473992086S0105X, 2086S0122X
WV119552086S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0114270000Medicaid
11955OtherHMO
OH0415214Medicaid
A72695Medicare UPIN
WV0462401Medicare ID - Type Unspecified
WV0114270000Medicaid