Basic Information
| Provider Information | |||||||||
| NPI: | 1558366088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLDEN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2065 N. STATE HWY | ||||||||
| Address2: | |||||||||
| City: | NAUVOO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623542472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088667169 | ||||||||
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| Practice Location | |||||||||
| Address1: | BROARDWAY AT 11TH STREET | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623507005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172238400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 11/07/2013 | ||||||||
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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 | M6837 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036118552 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000010001024 | 01 | ID | REGENCE BLUE SHIELD OF ID | OTHER | 003729600 | 05 | ID | MEDICAID | 72942 | 01 | ID | BLUE CROSS OF ID | OTHER |