MEDICARE: LAURA ELIZABETH HOLZUM M.D.

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	208000000X	Pediatrics Physician	036-134840	IL
2	208000000X	Pediatrics Physician	2019042541	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770870776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA ELIZABETH HOLZUM M.D.

Provider Business Mailing Address
First Line	:	3878 PERSHALL RD
Second Line	:
City	:	FERGUSON
State	:	MO
Zip	:	63135-1246
Country	:	US
Telephone Number	:	314-839-7500
Fax Number	:

Provider Business Practice Location Address
First Line	:	3878 PERSHALL RD
Second Line	:
City	:	FERGUSON
State	:	MO
Zip	:	63135-1246
Country	:	US
Telephone Number	:	314-839-7500
Fax Number	:

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

Provider Enumeration Date	:	06/29/2011
Last Update Date	:	05/06/2020

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