Provider Demographics
NPI:1871552232
Name:POLAM, CHANDRA R (MD)
Entity type:Individual
Prefix:
First Name:CHANDRA
Middle Name:R
Last Name:POLAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:121 FREEPORT RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BLAWNOX
Mailing Address - State:PA
Mailing Address - Zip Code:15238-3485
Mailing Address - Country:US
Mailing Address - Phone:412-784-7180
Mailing Address - Fax:412-784-7185
Practice Address - Street 1:121 FREEPORT RD STE 200
Practice Address - Street 2:
Practice Address - City:BLAWNOX
Practice Address - State:PA
Practice Address - Zip Code:15238-3485
Practice Address - Country:US
Practice Address - Phone:412-784-7180
Practice Address - Fax:412-784-7185
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038348L207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0211079000Medicaid
PA000915209Medicaid
PA000915209004Medicaid
OH0800020Medicaid
D71034Medicare UPIN