Provider Demographics
NPI:1174615173
Name:POLUN FAMILY FOOTCARE P C
Entity type:Organization
Organization Name:POLUN FAMILY FOOTCARE P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SILVERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-654-8602
Mailing Address - Street 1:19 BEECHAM CT
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-6001
Mailing Address - Country:US
Mailing Address - Phone:410-654-8602
Mailing Address - Fax:
Practice Address - Street 1:19 BEECHAM CT
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-6001
Practice Address - Country:US
Practice Address - Phone:410-654-8602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC4426119Medicaid
MD524101402Medicaid
961LMedicare ID - Type Unspecified
DC4426119Medicaid