Provider Demographics
NPI:1144258310
Name:POULOS, NICHOLAS E (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:E
Last Name:POULOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 W LINCOLN ST
Mailing Address - Street 2:SUITE 540
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1900
Mailing Address - Country:US
Mailing Address - Phone:618-222-1341
Mailing Address - Fax:618-222-1487
Practice Address - Street 1:340 W LINCOLN ST
Practice Address - Street 2:SUITE 540
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1900
Practice Address - Country:US
Practice Address - Phone:618-222-1341
Practice Address - Fax:618-222-1487
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036115133207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036115133Medicaid
ILK26007Medicare ID - Type Unspecified
IL036115133Medicaid