MEDICARE: DR. DANY BOULOS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	036141752	IL
2	207Q00000X	Family Medicine Physician	MD453720	PA
3	207Q00000X	Family Medicine Physician	01068800A	IN
4	207Q00000X	Family Medicine Physician	036141752	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000718849	OTHER	IN	ANTHEM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	036141752	OTHER	IL	STATE LICENSE

General Provider Information

NPI Number	:	1780830703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANY BOULOS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 820933
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19182-0933
Country	:	US
Telephone Number	:	215-926-9010
Fax Number	:	215-226-8685

Provider Business Practice Location Address
First Line	:	11000 ROOSEVELT BLVD
Second Line	:	360
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3961
Country	:	US
Telephone Number	:	215-677-1475
Fax Number	:	215-677-3082

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2008
Last Update Date	:	03/20/2024

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Directions to “ DR. DANY BOULOS M.D.” Practice Location

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