Provider Demographics
NPI:1497872675
Name:POULOSE, JAISE THEKKAN (MD)
Entity Type:Individual
Prefix:
First Name:JAISE
Middle Name:THEKKAN
Last Name:POULOSE
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:PO BOX 2400
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42241-2400
Mailing Address - Country:US
Mailing Address - Phone:270-887-0100
Mailing Address - Fax:
Practice Address - Street 1:3000 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6132
Practice Address - Country:US
Practice Address - Phone:701-364-8000
Practice Address - Fax:701-364-8078
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND11150207RC0000X
MN50104207RC0200X
LAMD.207663207RP1001X
KY53941207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100672860Medicaid
IAENROLLEDMedicaid
MNENROLLEDMedicaid
NDN714361Medicaid
WI35190900Medicaid
MN913427000Medicaid
ND10502Medicaid
MN913427000Medicaid
MN810000208Medicare PIN