Provider Demographics
NPI:1053422675
Name:POULOS, PHILLIP (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
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 1:204 N WESTOVER BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-2983
Mailing Address - Country:US
Mailing Address - Phone:229-888-6559
Mailing Address - Fax:229-436-4107
Practice Address - Street 1:2202 E OGLETHORPE BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31705-2940
Practice Address - Country:US
Practice Address - Phone:229-431-1423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022622207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5199230OtherAETNA
GA017231OtherBCBS - EAMC
GA055019OtherBCBS - RHIV
GA055019OtherBCBS - RHIV
GAD40890Medicare UPIN