Healthcare Provider Details

I. General information

NPI: 1295173128
Provider Name (Legal Business Name): PAIGE C HOLT, MD, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 06/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 E EMPIRE ST SUITE C
BLOOMINGTON IL
61704-3738
US

IV. Provider business mailing address

2502 E EMPIRE ST SUITE C
BLOOMINGTON IL
61704-3738
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-4444
  • Fax:
Mailing address:
  • Phone: 309-664-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number036116185
License Number StateIL

VIII. Authorized Official

Name: DR. PAIGE C HOLT
Title or Position: PRESIDENT
Credential: MD
Phone: 217-414-5342