Provider Demographics
NPI:1760876601
Name:POULOSE, BIJU (MD)
Entity Type:Individual
Prefix:
First Name:BIJU
Middle Name:
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 1:2525 CROOKS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4733
Mailing Address - Country:US
Mailing Address - Phone:248-731-7305
Mailing Address - Fax:
Practice Address - Street 1:2525 CROOKS RD STE 100
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4733
Practice Address - Country:US
Practice Address - Phone:248-731-7305
Practice Address - Fax:248-731-7388
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43011073192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty