MEDICARE: NATHANIEL OVERTON HOLLOWAY III M.D.

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	2085R0203X	Therapeutic Radiology Physician	036073542	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982659561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHANIEL OVERTON HOLLOWAY III M.D.

Provider Business Mailing Address
First Line	:	3400 N LAKE SHORE DR
Second Line	:	UNIT 9-B
City	:	CHICAGO
State	:	IL
Zip	:	60657-2827
Country	:	US
Telephone Number	:	773-947-7850
Fax Number	:	773-947-7852

Provider Business Practice Location Address
First Line	:	7531 S STONY ISLAND AVE
Second Line	:	BASEMENT
City	:	CHICAGO
State	:	IL
Zip	:	60649-3954
Country	:	US
Telephone Number	:	773-947-7850
Fax Number	:	773-947-7852

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

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	07/20/2009

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