Provider Demographics
NPI:1467477992
Name:FOULKE, DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:FOULKE
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 1:6121 N HERMITAGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-2305
Mailing Address - Country:US
Mailing Address - Phone:773-973-3005
Mailing Address - Fax:773-973-3006
Practice Address - Street 1:6121 N HERMITAGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-2305
Practice Address - Country:US
Practice Address - Phone:773-973-3005
Practice Address - Fax:773-973-3006
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35104207P00000X
IL036-059577207P00000X
IN01051286207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059577Medicaid
ILK40114Medicare PIN
C44567Medicare UPIN
ILK40167Medicare PIN
IL036059577Medicaid