Basic Information
Provider Information | |||||||||
NPI: | 1275515538 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | POULIS | ||||||||
FirstName: | DEMETRI | ||||||||
MiddleName: | TONY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1869 | ||||||||
Address2: |   | ||||||||
City: | FLETCHER | ||||||||
State: | NC | ||||||||
PostalCode: | 287321869 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286875616 | ||||||||
FaxNumber: | 8286508073 | ||||||||
Practice Location | |||||||||
Address1: | 50 HOSPITAL DR STE 1B | ||||||||
Address2: |   | ||||||||
City: | HENDERSONVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 287925252 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286506822 | ||||||||
FaxNumber: | 8286506827 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/14/2005 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 200301402 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208600000X | 200301402 | NC | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 13563 | 01 |   | BC/BS OF NC | OTHER | 8913563 | 05 | NC |   | MEDICAID |