Provider Demographics
NPI:1649591371
Name:POUSTINCHIAN, BRIAN REZA (DO)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:REZA
Last Name:POUSTINCHIAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4200
Mailing Address - Country:US
Mailing Address - Phone:630-208-3000
Mailing Address - Fax:630-762-7882
Practice Address - Street 1:300 RANDALL RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4200
Practice Address - Country:US
Practice Address - Phone:630-208-3000
Practice Address - Fax:630-762-7882
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036131483207R00000X
IL125058545207R00000X
IL036.131483208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE PTAN (GROUP)
ILP01248045OtherMEDICARE RAILROAD PTAN (INDIVIDUAL)
IL206147241OtherMEDICARE PTAN (INDIVIDUAL)
ILCA4748OtherMEDICARE RAILROAD PTAN (GROUP)
IL036131483Medicaid