Provider Demographics
NPI:1740299346
Name:POULOS, HARRY PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:HARRY
Middle Name:PAUL
Last Name:POULOS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3019 OLD GLENVIEW RD
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2908
Mailing Address - Country:US
Mailing Address - Phone:312-423-4200
Mailing Address - Fax:847-251-1013
Practice Address - Street 1:3019 OLD GLENVIEW RD
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2908
Practice Address - Country:US
Practice Address - Phone:312-423-4200
Practice Address - Fax:847-251-4348
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2010-07-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036062775207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD15191Medicare UPIN