Healthcare Provider Details

I. General information

NPI: 1790731545
Provider Name (Legal Business Name): ANGELA M HOLBROOK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 01/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 E BOONESLICK RD
WARRENTON MO
63383-2127
US

IV. Provider business mailing address

1836 LACKLAND HILL PKWY ATTN: CREDENTIALING
SAINT LOUIS MO
63146-3572
US

V. Phone/Fax

Practice location:
  • Phone: 636-456-0188
  • Fax:
Mailing address:
  • Phone: 314-989-0300
  • Fax: 314-810-1399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number103133
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number103133
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: