Healthcare Provider Details

I. General information

NPI: 1053675561
Provider Name (Legal Business Name): LINDSEY KRUMHOLZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LINDSEY VILLARRUBIA MD

II. Dates (important events)

Enumeration Date: 06/28/2012
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MEMORIAL DR SUITE 280
BELLEVILLE IL
62226-5368
US

IV. Provider business mailing address

4600 MEMORIAL DR SUITE 280
BELLEVILLE IL
62226-5368
US

V. Phone/Fax

Practice location:
  • Phone: 618-257-2800
  • Fax: 618-257-9802
Mailing address:
  • Phone: 618-257-2800
  • Fax: 618-257-9802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.137796
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2015015502
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: