Provider Demographics
NPI:1215056296
Name:HOLEMON, LANCE D (MD)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:D
Last Name:HOLEMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 W CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-5761
Mailing Address - Country:US
Mailing Address - Phone:312-421-4821
Mailing Address - Fax:
Practice Address - Street 1:1653 W CONGRESS PKWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3833
Practice Address - Country:US
Practice Address - Phone:312-421-4821
Practice Address - Fax:312-421-4208
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360764932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31603527OtherBCBS ILLINOIS
P00130149OtherRAILROAD MEDICARE
IL036076493Medicaid
P00130149OtherRAILROAD MEDICARE
E51043Medicare UPIN