Provider Demographics
NPI:1609899558
Name:POLASCIK, MICHAEL ANDREW (PT ATC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:POLASCIK
Suffix:
Gender:M
Credentials:PT ATC
Other - Prefix:
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Mailing Address - Street 1:1900 RIVERSIDE PKWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5925
Mailing Address - Country:US
Mailing Address - Phone:770-237-3475
Mailing Address - Fax:770-237-3756
Practice Address - Street 1:3708 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2404
Practice Address - Country:US
Practice Address - Phone:478-745-4206
Practice Address - Fax:478-254-5463
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2019-09-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA3716225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003158408AMedicaid