Healthcare Provider Details

I. General information

NPI: 1750901609
Provider Name (Legal Business Name): CHARLES LEE SOSEMAN HOLLIDAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 17TH AVE E STE 101
ALEXANDRIA MN
56308-5274
US

IV. Provider business mailing address

111 17TH AVE E STE 101
ALEXANDRIA MN
56308-5274
US

V. Phone/Fax

Practice location:
  • Phone: 320-762-1144
  • Fax: 320-762-1935
Mailing address:
  • Phone: 320-762-1144
  • Fax: 320-762-1935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number30945
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number69880
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number69880
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number14210215-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: