Basic Information
| Provider Information | |||||||||
| NPI: | 1003804519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POULOS | ||||||||
| FirstName: | DOROTHEA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| 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: | 12/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036-066780 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036066780 | 05 | IL | MEDICAID | 110021524 | 01 | RAILROAD RETIREMENT BOARD | OTHER |