Basic Information
| Provider Information | |||||||||
| NPI: | 1861986465 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DR POOLE PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 734639 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606734639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022426911 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3186 S MARYLAND PKWY | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891092317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027318000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2018 | ||||||||
| LastUpdateDate: | 10/29/2019 | ||||||||
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| AuthorizedOfficialLastName: | POOLE | ||||||||
| AuthorizedOfficialFirstName: | STANLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7025665343 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.