Provider Demographics
NPI:1699107797
Name:PAIGE C. HOLT
Entity type:Organization
Organization Name:PAIGE C. HOLT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:C
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-664-4444
Mailing Address - Street 1:2502 E EMPIRE ST
Mailing Address - Street 2:STE C
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3738
Mailing Address - Country:US
Mailing Address - Phone:310-664-4444
Mailing Address - Fax:309-664-5006
Practice Address - Street 1:2502 E EMPIRE ST
Practice Address - Street 2:STE C
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3738
Practice Address - Country:US
Practice Address - Phone:310-664-4444
Practice Address - Fax:309-664-5006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036116185208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty