Basic Information
| Provider Information | |||||||||
| NPI: | 1336187814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POLUKHIN | ||||||||
| FirstName: | ELENA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3006 FRANK ST | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551095501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516990633 | ||||||||
| FaxNumber: | 6517973592 | ||||||||
| Practice Location | |||||||||
| Address1: | 3015 UTAH AVE S | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAINT LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554263671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529331121 | ||||||||
| FaxNumber: | 9529459536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 45600 | MN | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 630074000 | 05 | MN | MEDICAID |