Healthcare Provider Details

I. General information

NPI: 1063770709
Provider Name (Legal Business Name): JONATHAN MICHAEL HOLMES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2012
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 PROVIDENCE PARK DR E STE. 201
MOBILE AL
36695-4622
US

IV. Provider business mailing address

610 PROVIDENCE PARK DR E STE. 201
MOBILE AL
36695-4622
US

V. Phone/Fax

Practice location:
  • Phone: 251-639-1300
  • Fax:
Mailing address:
  • Phone: 251-639-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34513
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: