Healthcare Provider Details

I. General information

NPI: 1326426107
Provider Name (Legal Business Name): THOMAS MONROE HOLLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: THOMAS HOLLAND BENOIST

II. Dates (important events)

Enumeration Date: 05/12/2015
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5145 N CALIFORNIA AVE ATTN GME OFFICE
CHICAGO IL
60625-3661
US

IV. Provider business mailing address

14532 E SADDLE CLUB RD
BONNIE IL
62816-3212
US

V. Phone/Fax

Practice location:
  • Phone: 773-989-3808
  • Fax:
Mailing address:
  • Phone: 314-323-9299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: