Individual
JAISE THEKKAN POULOSE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1 MEDICAL VILLAGE DR, EDGEWOOD, KY 41017-3403
(859) 757-2927
(859) 341-0203
Mailing address
PO BOX 635283, CINCINNATI, OH 45263-5283
(859) 757-2927
(859) 341-0203
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
11150
ND
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
50104
MN
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
Primary
53941
KY
207RP1001X
Pulmonary Disease Physician
MD.207663
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
10502
—
ND
05
—
35190900
—
WI
05
—
7100672860
—
KY
05
—
913427000
—
MN
05
—
ENROLLED
—
IA
05
—
ENROLLED
—
MN
05
—
N714361
—
ND
Enumeration date
03/23/2007
Last updated
08/06/2025
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