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General NPI Number Information
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NPI Number | 1497872675
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Entity Type | Individual
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Provider Name | JAISE THEKKAN POULOSE M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/23/2007
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Last Update Date | 08/06/2025
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Provider Practice Location Address
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Address Line | 1 MEDICAL VILLAGE DR
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City | EDGEWOOD
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State | KY
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Zip | 41017-3403
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Country | US
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Telephone | 859-757-2927
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Fax | 859-341-0203
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Provider Business Mailing Address
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Address Line | PO BOX 635283
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City | CINCINNATI
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State | OH
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Zip | 45263-5283
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Country | US
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Telephone | 859-757-2927
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Fax | 859-341-0203
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 11150
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License Number State | ND
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Taxonomy #2
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Taxonomy Code | 207RC0200X
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Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
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License Number | 50104
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License Number State | MN
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Taxonomy #3
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number | MD.207663
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License Number State | LA
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Taxonomy #4
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Taxonomy Code | 207RC0200X
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Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
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License Number | 53941
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License Number State | KY
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