Healthcare Provider Details

I. General information

NPI: 1720041031
Provider Name (Legal Business Name): EDWIN R HOLMES III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2006
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 S GRAND BLVD STE 2-315
SPOKANE WA
99202-1174
US

IV. Provider business mailing address

1314 S GRAND BLVD STE 2-315
SPOKANE WA
99202-1174
US

V. Phone/Fax

Practice location:
  • Phone: 509-999-7654
  • Fax:
Mailing address:
  • Phone: 509-999-7654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberMD00017183
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD00017183
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: