Basic Information
Provider Information
NPI: 1003804519
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: POULOS
FirstName: DOROTHEA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 87 N AIRLITE ST STE 130
Address2:  
City: ELGIN
State: IL
PostalCode: 601234991
CountryCode: US
TelephoneNumber: 8478883661
FaxNumber: 8478889964
Practice Location
Address1: 87 N AIRLITE ST STE 130
Address2:  
City: ELGIN
State: IL
PostalCode: 601234991
CountryCode: US
TelephoneNumber: 8478883661
FaxNumber: 8478889964
Other Information
ProviderEnumerationDate: 10/10/2005
LastUpdateDate: 09/12/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X036-066780ILY Allopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
03606678005IL MEDICAID
11002152401 RAILROAD RETIREMENT BOARDOTHER


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