Basic Information
| Provider Information | |||||||||
| NPI: | 1184680464 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLTH | ||||||||
| FirstName: | BYRON | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2925 CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122625000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11269 JEFFERSON HWY N | ||||||||
| Address2: | |||||||||
| City: | CHAMPLIN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553163123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632360600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 24071 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 508200500 | 05 | MN | MEDICAID |