Healthcare Provider Details

I. General information

NPI: 1821026519
Provider Name (Legal Business Name): PAIGE C. HOLT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PAIGE B. CORNETTE

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 02/25/2014
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: 309-664-5006
Mailing address:
  • Phone: 309-664-4444
  • Fax: 309-664-5006

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:
Title or Position:
Credential:
Phone: