=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386659175
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES B HOLMES, MD, SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2006
-----------------------------------------------------
Last Update Date | 04/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10547 S EWING AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-6220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-221-1690
-----------------------------------------------------
Fax | 773-221-1675
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7703 S CREGIER AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60649-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-221-1690
-----------------------------------------------------
Fax | 773-221-1675
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CHARLES B HOLMES
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 773-221-1690
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------