Provider Demographics
NPI:1215088000
Name:POLO, THERESE L (MD)
Entity type:Individual
Prefix:DR
First Name:THERESE
Middle Name:L
Last Name:POLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:GILLESPIE
Mailing Address - State:IL
Mailing Address - Zip Code:62033-1100
Mailing Address - Country:US
Mailing Address - Phone:217-839-3900
Mailing Address - Fax:217-839-1313
Practice Address - Street 1:807 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:GILLESPIE
Practice Address - State:IL
Practice Address - Zip Code:62033-1100
Practice Address - Country:US
Practice Address - Phone:217-839-3900
Practice Address - Fax:217-839-1313
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
427533OtherHEALTHLINK
IL0005932020OtherBLUE CROSS BLUE SHEILD
ILH07056Medicare UPIN