MEDICARE: DR. JEFFREY SCOTT POULTER 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	2086S0122X	Plastic and Reconstructive Surgery Physician	MDR5N96	MO
2	208200000X	Plastic Surgery Physician		IL
3	2086S0122X	Plastic and Reconstructive Surgery Physician		IL

General Provider Information

NPI Number	:	1174521074
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY SCOTT POULTER M.D.

Provider Business Mailing Address
First Line	:	1505 EASTLAND DR
Second Line	:	STE 350
City	:	BLOOMINGTON
State	:	IL
Zip	:	61701-3534
Country	:	US
Telephone Number	:	309-663-1222
Fax Number	:	309-663-0580

Provider Business Practice Location Address
First Line	:	1505 EASTLAND DR
Second Line	:	STE 350
City	:	BLOOMINGTON
State	:	IL
Zip	:	61701-3534
Country	:	US
Telephone Number	:	309-663-1222
Fax Number	:	309-663-0580

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

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	12/19/2007

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