Basic Information
Provider Information | |||||||||
NPI: | 1427026319 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOLUBOWITCH | ||||||||
FirstName: | EDWARD | ||||||||
MiddleName: | JOHN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2202 N FORBES BLVD | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857451412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5208727536 | ||||||||
FaxNumber: | 5208727929 | ||||||||
Practice Location | |||||||||
Address1: | 400 W CAMINO CASA VERDE | ||||||||
Address2: | #100 | ||||||||
City: | GREEN VALLEY | ||||||||
State: | AZ | ||||||||
PostalCode: | 856143564 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206251760 | ||||||||
FaxNumber: | 5206481394 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2006 | ||||||||
LastUpdateDate: | 02/08/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101036227 | VA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 45484 | AZ | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0103774 | 01 | VA | UNITED HEALTHCARE PROVIDE | OTHER | 466797 | 01 | VA | ANTHEM PROVIDER NUMBER | OTHER | 671649 | 05 | AZ |   | MEDICAID | 005629250 | 05 | VA |   | MEDICAID | 101808 | 01 | VA | CIGNA PROVIDER NUMBER | OTHER | 79292 | 01 | VA | SOUTHERN HEALTH PROVIDER | OTHER | CB1505 | 01 | VA | RAILROAD MEDICARE GROUP # | OTHER | 466796 | 01 | VA | ANTHEM GROUP NUMBER | OTHER | 005629250 | 01 | VA | VIRGINIA PREMIER PROVIDER | OTHER | 0164R | 01 | VA | BCBS OF NC COSTWISE | OTHER | 080018162 | 01 | VA | RAILROAD MEDICARE PROVIDE | OTHER | 2129327 | 01 | VA | MAMSI PROVIDER NUMBER | OTHER |