Provider Demographics
NPI:1114991577
Name:BOULOS, RIDA W (MD)
Entity Type:Individual
Prefix:
First Name:RIDA
Middle Name:W
Last Name:BOULOS
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 1:1 ILLINI DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-2576
Mailing Address - Country:US
Mailing Address - Phone:309-671-8503
Mailing Address - Fax:
Practice Address - Street 1:DEPT OF OB / GYN
Practice Address - Street 2:530 NE GLEN OAK
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-3024
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07215036OtherBCBS
ILC41840Medicare UPIN
IL639810Medicare ID - Type UnspecifiedMEDICARE