Healthcare Provider Details

I. General information

NPI: 1295718781
Provider Name (Legal Business Name): RONALD HOLT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 02/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 W 95TH ST
EVERGREEN PARK IL
60805-2746
US

IV. Provider business mailing address

2961 TWO PATHS DR
WOODRIDGE IL
60517-4512
US

V. Phone/Fax

Practice location:
  • Phone: 708-422-4221
  • Fax: 708-422-4415
Mailing address:
  • Phone: 708-422-4221
  • Fax: 708-422-4415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number036066295
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number036066295
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036.066295
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier036033295
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBLUE CROSS BLUE SHIELD
# 2
Identifier036066295
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: