Provider Demographics
NPI:1982835526
Name:POULOSE, MON C (MD)
Entity Type:Individual
Prefix:DR
First Name:MON
Middle Name:C
Last Name:POULOSE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3225 N EVERGREEN DRIVE NE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525
Mailing Address - Country:US
Mailing Address - Phone:716-348-7834
Mailing Address - Fax:616-364-6400
Practice Address - Street 1:3225 N EVERGREEN DRIVE NE
Practice Address - Street 2:SUITE 301
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:716-348-7834
Practice Address - Fax:616-364-6400
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-30
Last Update Date:2014-01-29
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Provider Licenses
StateLicense IDTaxonomies
MI283Q00000X
MI43010999832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No283Q00000XHospitalsPsychiatric Hospital