Healthcare Provider Details

I. General information

NPI: 1982835526
Provider Name (Legal Business Name): MON C POULOSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2009
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 N EVERGREEN DRIVE NE SUITE 301
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

3225 N EVERGREEN DRIVE NE SUITE 301
GRAND RAPIDS MI
49525
US

V. Phone/Fax

Practice location:
  • Phone: 716-348-7834
  • Fax: 616-364-6400
Mailing address:
  • Phone: 716-348-7834
  • Fax: 616-364-6400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301099983
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: