Healthcare Provider Details

I. General information

NPI: 1316977804
Provider Name (Legal Business Name): ERNEST SAMUEL HOLMES IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 S JEFFERSON ST
NEOSHO MO
64850-1769
US

IV. Provider business mailing address

PO BOX 3810
JOPLIN MO
64803
US

V. Phone/Fax

Practice location:
  • Phone: 417-451-0778
  • Fax: 417-451-0779
Mailing address:
  • Phone: 417-451-0778
  • Fax: 417-451-0779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number115096
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: