Provider Demographics
NPI:1760801120
Name:POULOS, ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:POULOS
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 1:900 W TEMPLE AVE STE 1500
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2121
Mailing Address - Country:US
Mailing Address - Phone:217-347-0458
Mailing Address - Fax:217-342-2992
Practice Address - Street 1:900 W TEMPLE AVE STE 1500
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2121
Practice Address - Country:US
Practice Address - Phone:217-347-0458
Practice Address - Fax:217-342-2992
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301113522207Q00000X
IL036161439207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine