Healthcare Provider Details

I. General information

NPI: 1558366088
Provider Name (Legal Business Name): MICHAEL D HOLDEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BROARDWAY AT 11TH STREET
QUINCY IL
62350-7005
US

IV. Provider business mailing address

2065 N. STATE HWY
NAUVOO IL
62354-2472
US

V. Phone/Fax

Practice location:
  • Phone: 217-223-8400
  • Fax:
Mailing address:
  • Phone: 208-866-7169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM6837
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036118552
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: