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NPI Code Detail

MEDICARE: MICHAEL BOULOS M.D.

MEDICARE: MICHAEL 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
1207RC0200XCritical Care Medicine (Internal Medicine) Physician01054000AIN

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1P01214629OTHERINRR MEDICARE PTAN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1083618581
Entity Type Code : Individual
Provider Name (Legal Business Name) : MICHAEL BOULOS M.D.
Provider Business Mailing Address
First Line : 8333 NAAB RD STE 250
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46260-1983
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 8333 NAAB RD STE 250
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46260-1983
Country : US
Telephone Number : 317-338-5100
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/13/2005
Last Update Date : 10/17/2024

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