Provider Demographics
NPI:1861670275
Name:POLLACK
Entity type:Organization
Organization Name:POLLACK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:POLLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-749-5881
Mailing Address - Street 1:1699 KING STREET
Mailing Address - Street 2:SUITE 208
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-4585
Mailing Address - Country:US
Mailing Address - Phone:860-749-5881
Mailing Address - Fax:860-776-2420
Practice Address - Street 1:1699 KING ST
Practice Address - Street 2:SUITE 208
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-6051
Practice Address - Country:US
Practice Address - Phone:860-749-5881
Practice Address - Fax:860-776-2420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0410222084S0012X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001410224Medicaid
CT130000587Medicare PIN