Provider Demographics
NPI:1265617047
Name:BOULIS, EMAN (MD)
Entity type:Individual
Prefix:
First Name:EMAN
Middle Name:
Last Name:BOULIS
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 1:210 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-1898
Mailing Address - Country:US
Mailing Address - Phone:641-236-7511
Mailing Address - Fax:641-236-2058
Practice Address - Street 1:210 4TH AVE
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-1898
Practice Address - Country:US
Practice Address - Phone:641-236-7511
Practice Address - Fax:641-236-2058
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD433023207R00000X
MS20150207RR0500X
IAMD-41825207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAMD-41825OtherIA LICENSE
IA1246481OtherIA CSA
PA102065830Medicaid
PA102065830Medicaid
PA121362S8GMedicare PIN