Basic Information
| Provider Information | |||||||||
| NPI: | 1740471077 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLLES-SOBOTA | ||||||||
| FirstName: | STACI | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 PICCARD DRIVE | ||||||||
| Address2: | SUITE 202 EMERGENCY MEDICINE ASSOCIATES | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208504303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019217900 | ||||||||
| FaxNumber: | 3019217915 | ||||||||
| Practice Location | |||||||||
| Address1: | 8384 CHARLOTTE HWY | ||||||||
| Address2: | |||||||||
| City: | INDIAN LAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297076532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036899037 | ||||||||
| FaxNumber: | 7036899109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2007 | ||||||||
| LastUpdateDate: | 09/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 37739 | SC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 0102202037 | VA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 37739 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 377391 | 05 | SC | MEDICAID |