Basic Information
| Provider Information | |||||||||
| NPI: | 1992149835 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLIASHENKO | ||||||||
| FirstName: | STANISLAV | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10700 E GEDDES AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Practice Location | |||||||||
| Address1: | 1364 CLIFTON RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047780263 | ||||||||
| FaxNumber: | 4047781444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2013 | ||||||||
| LastUpdateDate: | 09/11/2019 | ||||||||
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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 | 207R00000X | 6240 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2085R0202X | 61493 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | NA1215148 | 01 | NE | MEDICARE | OTHER | 9000170766 | 05 | CO | MEDICAID | 111257135 | 01 | KS | MEDICARE | OTHER | 832216 | 01 | CO | MEDICARE | OTHER | 832219 | 01 | CO | MEDICARE | OTHER | KA3249126 | 01 | KS | MEDICARE | OTHER | 832218 | 01 | CO | MEDICARE | OTHER | NA1214147 | 01 | NE | MEDICARE | OTHER | NA2517124 | 01 | NE | MEDICARE | OTHER |