MEDICARE: DR. JANETTE L HOLUB MD, MPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	036121113	IL
2	2086S0127X	Trauma Surgery Physician	51715	TN
3	2086S0127X	Trauma Surgery Physician	01075879A	IN

General Provider Information

NPI Number	:	1265609879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JANETTE L HOLUB MD, MPH

Provider Business Mailing Address
First Line	:	11109 PARKVIEW PLAZA DR # 117
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11141 PARKVIEW PLAZA DR
Second Line	:	SUITE 305
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1713
Country	:	US
Telephone Number	:	260-266-8900
Fax Number	:	260-266-8935

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2008
Last Update Date	:	10/07/2022

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