Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YX0905X | Otolaryngology/Facial Plastic Surgery | 85522 | GA |
NPI | 1689084022 |
---|---|
Provider Name | Marc Polacco |
First Address | Evans, GA 30809-3115 |
Second Address | Evans, GA 30809-3115 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/05/2014 |
Last Update Date | 26/08/2021 |