Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 81894 | MA |
N | 2081P2900X | Pain Medicine | 81894 | MA |
NPI | 1063402352 |
---|---|
Provider Name | Dr. Gary I Polykoff |
First Address | Charlestown, MA 02129-9142 |
Second Address | Boston, MA 02114-3117 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/10/2005 |
Last Update Date | 22/09/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
081894 | TUFTS HEALTH PLAN (01) | MA |
3186733 | (05) | MA |
G80376 | (02) | |
J19417 | BCBS MA (01) | MA |