Provider Demographics
NPI:1316977804
Name:HOLMES, ERNEST SAMUEL IV (MD)
Entity type:Individual
Prefix:
First Name:ERNEST
Middle Name:SAMUEL
Last Name:HOLMES
Suffix:IV
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:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803
Mailing Address - Country:US
Mailing Address - Phone:417-451-0778
Mailing Address - Fax:417-451-0779
Practice Address - Street 1:336 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850-1769
Practice Address - Country:US
Practice Address - Phone:417-451-0778
Practice Address - Fax:417-451-0779
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO115096208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100149160AMedicaid
KS100317780AMedicaid
MO203756804Medicaid
MO115234OtherANTHEM
KS100317780AMedicaid