Basic Information
| Provider Information | |||||||||
| NPI: | 1467424986 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLLACK | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 475 S DOBSON RD | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852245605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807283753 | ||||||||
| FaxNumber: | 4807283753 | ||||||||
| Practice Location | |||||||||
| Address1: | 475 S DOBSON RD | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852245605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807283753 | ||||||||
| FaxNumber: | 4807283753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 10/15/2009 | ||||||||
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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 | 6007 | MT | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 25105 | AZ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000641 | 01 | BCBC ER GROUP | OTHER | 0034714 | 05 | MT | MEDICAID |