Healthcare Provider Details

I. General information

NPI: 1083709166
Provider Name (Legal Business Name): PHILIP HOLLOWAY DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 E COURT STREET
PARIS IL
61944-2460
US

IV. Provider business mailing address

727 E COURT STREET
PARIS IL
61944-2460
US

V. Phone/Fax

Practice location:
  • Phone: 217-465-8411
  • Fax: 217-465-3184
Mailing address:
  • Phone: 217-465-8411
  • Fax: 217-465-3184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016003369
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000548A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: