Basic Information
| Provider Information | |||||||||
| NPI: | 1144242223 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLKA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4930 N TURNBERRY DR | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549138680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153152318 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1818 N MEADE ST | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549113454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207314101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 02/09/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036-108682 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 53394 | WI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036108682 | 05 | IL | MEDICAID | 34715700 | 05 | WI | MEDICAID | P00054858 | 01 | IL | MEDICARE RAILROAD | OTHER |