Provider Demographics
NPI:1679678874
Name:POULOS, CHRISTINE M (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:M
Last Name:POULOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2403 HARNISH DR
Mailing Address - Street 2:STE 101
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-6803
Mailing Address - Country:US
Mailing Address - Phone:224-520-0087
Mailing Address - Fax:
Practice Address - Street 1:2403 HARNISH DR STE 101
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102
Practice Address - Country:US
Practice Address - Phone:224-333-0730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-090598208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-090598OtherILLINOIS LICENSE PHYSICIAN AND SURGEON