Provider Demographics
NPI:1437252780
Name:POLK, SAMUEL C (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:C
Last Name:POLK
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:PO BOX 649113
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75264-9113
Mailing Address - Country:US
Mailing Address - Phone:903-571-3844
Mailing Address - Fax:855-343-5763
Practice Address - Street 1:7900 AIRWAYS BLVD STE 2
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4113
Practice Address - Country:US
Practice Address - Phone:601-420-2040
Practice Address - Fax:855-343-5763
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41433208100000X
MS340032081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS34003OtherMEDICAL LICENSE
TN41433OtherMEDICAL LICENSE