MEDICARE: KEVIN HOLTHAUS MD

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	174400000X	Specialist	ME43785	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	110241847	OTHER	FL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	15832	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1003893215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN HOLTHAUS MD

Provider Business Mailing Address
First Line	:	PO BOX 17809
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32245-7809
Country	:	US
Telephone Number	:	904-723-0015
Fax Number	:	904-338-0951

Provider Business Practice Location Address
First Line	:	1361 13TH AVE S
Second Line	:	STE 150
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-3233
Country	:	US
Telephone Number	:	904-242-7177
Fax Number	:	904-242-7133

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

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	11/21/2007

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Directions to “ KEVIN HOLTHAUS MD” Practice Location

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