Basic Information
| Provider Information | |||||||||
| NPI: | 1063416006 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POLLACK | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 SOUTHHALL LN | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078752080 | ||||||||
| FaxNumber: | 4076503455 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 OFFICE CENTER DR | ||||||||
| Address2: | SUITE 195 | ||||||||
| City: | FT WASHINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190343220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158367900 | ||||||||
| FaxNumber: | 2158367923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2005 | ||||||||
| LastUpdateDate: | 03/14/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | MD022348E | PA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 0057083000 | 01 | PA | KEYSTONE HP EAST | OTHER | 0004913 | 01 | PA | AETNA | OTHER | C29807 | 05 | PA | MEDICAID |