Basic Information
| Provider Information | |||||||||
| NPI: | 1033111331 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLMES | ||||||||
| FirstName: | JED | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7111 E 21ST STREET N | ||||||||
| Address2: | SUITE A | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166842851 | ||||||||
| FaxNumber: | 3166867338 | ||||||||
| Practice Location | |||||||||
| Address1: | 7111 E 21ST STREET N | ||||||||
| Address2: | SUITE A | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166842851 | ||||||||
| FaxNumber: | 3166867338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 10/16/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 04-18241 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 80186351 | 01 | KS | RAILROAD MEDICARE | OTHER | 110718 | 01 | KS | BLUE CROSS GROUP | OTHER | 101601 | 01 | KS | BLUE CROSS INDIVIDUAL | OTHER | 100084320B | 05 | KS | MEDICAID | 101601 | 01 | KS | CHAMPUS | OTHER | 621541 | 01 | IA | FIRSTGUARD | OTHER | 100416440A | 05 | KS | MEDICAID |